Medical Records Technician (CDIS In/Out)

Veterans Health Administration • Atlanta, GA

13d • Onsite

About The Position

This position is in the Health Information Management (HIM) Section under the Business Office at the VA Medical Center in Atlanta, Georgia. The Medical Records Technician (Coder) analyzes patient health records and assigns alphanumeric codes to diagnoses and procedures. The role focuses on clinical documentation improvement for inpatient and outpatient care, supporting accurate coding, workload capture, quality measures, reimbursement, funding, and resource allocation.

The incumbent reviews clinical documentation for quality, completeness, and support for coded diagnoses and procedures; educates clinical staff and providers on documentation practices; and serves as a liaison between HIM and clinical staff. Inpatient CDI involves concurrent review while patients are in-house, while outpatient CDI involves retrospective review of outpatient encounters, ideally before coding and billing. The position also supports documentation and coding requirements related to the Veterans Equitable Resource Allocation (VERA) program.

The position is full-time, Monday through Friday, 8:00 a.m. to 4:30 p.m., subject to change based on agency need. Telework is available five days per pay period. This is not a virtual position. The work is primarily sedentary, involving extended periods sitting at a desk and daily computer use.

Requirements

• U.S. citizenship, subject to the stated exception for non-citizens when qualified citizens cannot be recruited under VA policy.
• Proficiency in spoken and written English.
• Meet the basic experience and education requirements through one of the listed pathways: one year of creditable experience; a qualifying associate degree; completion of an eligible coding training program; or an accepted combination of experience and education/training.
• Possess an eligible AHIMA, AAPC, or ACDIS certification: apprentice/associate-level or mastery-level certification through AHIMA or AAPC, or clinical documentation improvement certification through AHIMA or ACDIS. Mastery-level certification is required above journey level, except that a CDI certification may substitute for CDI specialist assignments.
• For GS-09 CDIS Outpatient and Inpatient: meet one of the listed grade-determination pathways, including qualifying journey-level coder experience; an associate degree or higher plus three years of CDI experience and specified coursework; mastery-level certification plus two years of CDI experience; or qualifying clinical experience plus one year of CDI experience.
• Must pass a pre-employment physical examination and undergo a background/security investigation.
• Must comply with the seasonal influenza vaccination program for VA Health Care Personnel.
• Must complete application and onboarding requirements, including acceptable identification for employment.
• Must serve a one- or two-year trial period, subject to written certification for continued employment.
• Physical work is primarily sedentary, with long periods sitting at a desk and daily computer use.

Nice To Haves

• Two years of experience in clinical documentation improvement (CDIS).

Responsibilities

• Review the overall quality and completeness of clinical documentation.
• Apply knowledge of medical terminology, anatomy and physiology, disease processes, treatment modalities, diagnostic tests, medications, procedures, health services, and organizational structure to select appropriate codes.
• Review clinical documentation and provide education to clinical staff on inpatient and outpatient episodes of care.
• Prepare and conduct provider education on health-record documentation processes and their effects on coding, workload, quality measures, reimbursement, and funding.
• Educate providers on the need for accurate, complete, and sufficiently specific documentation that supports selected codes.
• Follow accepted coding practices, guidelines, and conventions to ensure ethical, accurate, and complete coding.
• Ensure provider documentation supports coded diagnoses and procedures.
• Serve as a liaison between HIM and clinical staff to improve health-record documentation quality, education, completeness, and accuracy.
• Review documentation and facilitate health-record modifications to ensure accurate severity of illness, risk of mortality, complexity of care, and utilization of resources.
• Conduct concurrent inpatient documentation reviews and retrospective outpatient encounter reviews, ideally before coding and billing.
• Query clinical staff to clarify ambiguous, conflicting, or incomplete documentation, and review query appropriateness and responses through query reports.
• Obtain corrective action plans from responsible clinical service directors and recommend improvements or changes in documentation practices when applicable.
• Review VERA input on missed documentation opportunities and coordinate provider education with the VERA coordinator.
• Ensure documentation supports codes under guidelines for diagnoses, procedures, and other criteria used in the VERA program.
• Develop and conduct seminars, workshops, short courses, informational briefings, and conferences on health-record documentation and educational and functional training requirements for clinical and HIM staff.

Benefits

• Federal employees and their families have access to a comprehensive benefits package; specific benefits depend on position eligibility.
• Selected applicants may qualify to receive annual-leave service credit based on prior federal work or military service, subject to request and approval.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree