Clinical Documentation Specialist Jobs

About The Position

Requirements

• U.S. citizenship, subject to the stated VA exception for non-citizens when qualified citizens cannot be recruited.
• Proficiency in spoken and written English.
• Meet the basic experience and education qualification through one of the stated pathways: one year of qualifying experience; a qualifying associate degree; completion of an approved or qualifying coding training program; or an allowable combination of experience and education.
• Hold the required AHIMA, AAPC, or ACDIS certification: apprentice/associate-level certification, mastery-level certification, or clinical documentation improvement certification, as applicable to the position.
• For the GS-09 grade, meet one of the stated experience/education pathways: one year of qualifying journey-level MRT (Coder-Outpatient and Inpatient) experience; an associate degree or higher plus three years of clinical documentation improvement experience and specified coursework; mastery-level certification plus two years of clinical documentation improvement experience; or qualifying clinical experience such as RN, M.D., or DO plus one year of clinical documentation improvement experience.
• At the GS-09 level, have either a mastery-level certification or a clinical documentation improvement certification.
• Demonstrate knowledge of coding and documentation concepts, guidelines, and clinical terminology.
• Demonstrate knowledge of anatomy, physiology, pathophysiology, and pharmacology to interpret health records and identify opportunities for more precise or 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.
• Have extensive knowledge of coding rules and regulations, including ICD-CM, ICD-PCS, CPT, HCPCS, CC/MCC, MS-DRG structure, and POA indicators.
• Know severity of illness, risk of mortality, and complexity of inpatient care, as well as outpatient CPT Evaluation and Management criteria.
• Know training methods and teaching skills sufficient to conduct staff continuing education.
• Meet VA pre-employment requirements, including background/security investigation and physical examination; selected applicants are subject to drug screening and must participate in the seasonal influenza vaccination program.
• Complete the required online onboarding and application documentation.
• Serve a one- or two-year trial period.
• Maintain required certification through continuing education.
• Live within or be willing to relocate within commuting distance of the duty location.

Responsibilities

• Review inpatient and outpatient medical records to identify clinical documentation improvement opportunities.
• Collaborate with physicians, nurses, coders, and other healthcare staff to clarify and improve documentation accuracy.
• Analyze health record documentation for completeness, specificity, and compliance with regulatory requirements.
• Conduct concurrent and retrospective patient-record reviews to support accurate code assignment and reimbursement.
• Educate and train clinical staff on documentation standards, coding guidelines, and clinical documentation improvement initiatives.
• Monitor changes in coding regulations, documentation requirements, and industry standards, and communicate their impacts to stakeholders.
• Assist with policy development and process improvement activities related to documentation integrity and compliance.
• Evaluate documentation to support accurate assignment of diagnoses, procedures, severity of illness, risk of mortality, and quality measures.
• Perform clinical documentation audits, data analysis, and reporting to identify trends and improvement opportunities.
• Participate in multidisciplinary rounds and serve as a clinical documentation resource for healthcare teams.
• Maintain documentation improvement databases and prepare reports for leadership and program oversight.
• Ensure compliance with VA policies, coding guidelines, privacy requirements, and health information management standards.

Benefits

• Federal employee benefits package; eligibility depends on the position and employment status.
• Potential credit toward annual leave accrual based on prior work or military service, subject to request and approval before appointment.