Medical Records Technician (CDIS) Inpatient/Outpatient

Veterans Health Administration • Fayetteville, NC

4d • Hybrid

About The Position

This position is in the Health Information Management section at the Fayetteville NC VA Coastal Health Care System. The Medical Records Technician (Coder) classifies medical data from patient health records in hospital and physician-based settings by analyzing and abstracting records and assigning alphanumeric codes to diagnoses and procedures.

The position performs inpatient and outpatient clinical documentation improvement (CDI). It serves as a liaison between health information management and clinical staff, supporting the quality, completeness, and accuracy of health record documentation. The role reviews documentation and facilitates clarifications to ensure it reflects patients’ conditions, services rendered, workload, and resource use. Inpatient CDI involves concurrent review while patients are in-house; outpatient CDI involves retrospective review of encounters, ideally before coding and billing, and provider education.

The technician serves as a technical expert on health record content and documentation requirements; conducts reviews, analyzes and reports data, and coordinates corrective action and education. The position also supports documentation requirements related to the Veterans Equitable Resource Allocation (VERA) program and provides clinical staff with technical guidance on regulations, policy, coding, reimbursement, workload, nomenclature, and sequencing.

The work schedule is Monday through Friday, 8:00 a.m. to 4:30 p.m. Telework is available; this is not a virtual position. A recruitment or relocation incentive may be authorized for applicants new to federal service only: $6,381.50 in exchange for a two-year service agreement. Permanent Change of Station is not authorized.

Requirements

• U.S. citizenship, subject to the stated exception under VA policy for non-citizens when qualified citizens cannot be recruited.
• Proficiency in spoken and written English.
• Meet the basic experience or education requirement through one of the stated pathways: one year of creditable relevant experience; an associate’s degree in health information technology/management or a related degree with at least 12 relevant semester hours; completion of an eligible coding training program of approximately one year or more; or an equivalent combination of qualifying experience and education.
• For GS-09, meet one of the stated grade pathways: one year of experience equivalent to the GS-08 inpatient/outpatient coder level; an associate’s degree or higher plus three years of CDI experience and specified coursework; mastery-level AHIMA or AAPC certification plus two years of CDI experience; or clinical experience such as RN, MD, or DO plus one year of CDI experience.
• Hold either a mastery-level coding certification or a clinical documentation improvement certification for the GS-09 level. Listed certifications include CCS, CCS-P, RHIT, RHIA, CPC, COC, CIC, CDIP, and CCDS.
• Demonstrate knowledge of coding and documentation concepts, guidelines, and clinical terminology.
• Demonstrate knowledge of anatomy, physiology, pathophysiology, and pharmacology to analyze health records and identify opportunities for more complete documentation.
• Be able to collect and analyze data and present results in various formats, including reports to organizational levels.
• Be able to establish and maintain strong verbal and written communication with providers.
• Know healthcare documentation regulations, including The Joint Commission, CMS, and VA guidelines.
• Know coding systems and rules, including ICD-CM, ICD-PCS, CPT, HCPCS, CC/MCC, MS-DRG structure, and POA indicators.
• Know inpatient severity of illness, risk of mortality, and complexity of care, as well as outpatient CPT Evaluation and Management criteria.
• Know training methods and teaching skills sufficient to conduct staff continuing education.
• Complete a background/security investigation, online onboarding, and required pre-employment identification and application documentation.
• Participate in the seasonal influenza vaccination program as a condition of employment.
• Serve a one- or two-year trial period, subject to written certification for continued employment after the trial period.
• Meet the physical demands described for the role: light lifting under 15 pounds, moderate carrying of 15–44 pounds, reaching above shoulder, finger use, standing 4–6 hours, hearing, and adequate vision to read and prepare documents.
• For education used to qualify, use credentials recognized by the U.S. Department of Education; foreign education requires a Certificate of Foreign Equivalency with transcripts.

Nice To Haves

• Extensive knowledge of coding rules and regulations, ICD-CM and ICD-PCS, CPT, HCPCS, CC/MCC, MS-DRG structure, and POA indicators.

Responsibilities

• Perform the duties of a Medical Records Technician (Coder) for inpatient and outpatient records.
• Serve as liaison between health information management and clinical staff to improve the quality, education, completeness, and accuracy of health record documentation.
• Review documentation and facilitate health record modifications to accurately reflect severity of illness, risk of mortality, complexity of care, and resource utilization.
• Identify documentation improvement opportunities, ensuring diagnoses and procedures are specific, address acute and chronic conditions, and reflect patients’ true health status.
• Develop or update medical center policy pertaining to clinical documentation improvement.
• Serve as a technical expert in health record content and documentation requirements.
• Review the overall quality and completeness of clinical documentation, including concurrent inpatient records and retrospective outpatient encounters.
• Query clinical staff to clarify ambiguous, conflicting, or incomplete documentation, and review query appropriateness and responses through query reports.
• Develop review criteria; collect, graph, and analyze data; prepare reports; and communicate findings to appropriate groups and leadership.
• Obtain corrective action plans from clinical service directors and recommend improvements or changes to documentation practices when applicable.
• Follow documentation requirements established by accrediting agency guidelines, regulations, policies, and medical-legal requirements; monitor industry and regulatory changes and identify education needs.
• Develop and implement training and education programs for clinical staff, including seminars, workshops, short courses, briefings, and conferences.
• Educate clinical staff individually or in groups on current documentation standards, improvement techniques, and accurate and ethical documentation practices.
• Apply knowledge of medical terminology, anatomy and physiology, disease processes, treatment modalities, diagnostic tests, medications, and procedures to support proper code selection.
• Review documentation and educate clinical staff on inpatient and outpatient episodes, including admissions and discharges, observation, emergency department and urgent care, and clinic visits.
• Review VERA input regarding documentation opportunities and coordinate provider education with the VERA coordinator.
• Ensure documentation supports codes and criteria used to classify VA patients under the VERA program.
• Assist facility staff with documentation requirements and provide technical support concerning regulations, policy, coding, resident supervision, reimbursement, workload, nomenclature, and sequencing.
• Perform other duties as assigned.

Benefits

• Federal employee benefits package for employees and their families; specific benefits depend on position type and eligibility.
• Annual leave accrual may be credited for qualifying prior federal work or military service, subject to request and approval.
• A recruitment or relocation incentive of $6,381.50 may be authorized for applicants new to federal service who agree to a two-year service period.

What This Job Offers

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