U.S. Department of Veterans Affairs - Agency Wide
Clinical Documentation Improvement Specialist (CDIS)
The Medical Records Technician (Coder) Clinical Documentation Improvement Specialist (CDIS) is responsible for facilitating improved overall quality, education, and completeness, and accuracy of medical record documentation as well as promoting appropriate clinical documentation through extensive interaction with physicians, other patient caregivers, HIM coding staff and other associated staff to ensure clinical documentation and services rendered to patients is complete and accurate for appropriate workload capture and resource allocations. Serves as technical expert in health record content and documentation, developing criteria, collecting data, graphing and analyzing results, creating reports, and communicating in writing and/or in person to appropriate leadership and groups. Recommends improvements or changes in documentation as deemed necessary. Adheres to established documentation requirements as outlined by accrediting agencies guidelines, regulations, policy and medical-legal requirements. Responsible for the development and implementation of active training/education programs (i.e. seminars, workshops, short courses, informational briefings, and conferences) for all providers to ensure the CDIS program objectives are met.
Monday - Friday 8:00 a.m. to 4:30 p.m.
Financial Disclosure Report:
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Applies comprehensive knowledge of medical terminology, anatomy & physiology, disease processes, treatment modalities, diagnostic tests, medications, procedures as well as the principles and practices of health services and the organizational structure to ensure proper code selection.
Selects and assigns codes from the current version of several coding systems to include current versions of the International Classification of Diseases (ICD), Current Procedural Terminology (CPT), and/or Healthcare Common Procedure Coding System (HCPCS).
Adheres to accepted coding practices, guidelines and conventions when choosing the most appropriate diagnosis, operation, procedure, ancillary, or Evaluation and Management code to ensure ethical, accurate, and complete coding. Also applies codes based on guidelines specific to certain diagnoses, procedures, and other criteria (in inpatient and outpatient settings) used to classify patients under the Veterans Equitable Resource Allocation (VERA) program that categorizes all VA patients into specific classes representing their clinical conditions and resource needs.
Monitors ever-changing regulatory and policy requirements affecting coded information for the full spectrum of services provided by the VAMC. Timely compliance with coding changes is crucial to the accuracy of the facility database as well as all cost recovery programs.
Assists facility staff with documentation requirements to completely and accurately reflect the patient care provided; provides technical support in the areas of regulations and policy, coding requirements, resident supervision, reimbursement, workload, accepted nomenclature, and proper sequencing. Ensures provider documentation is complete and supports the diagnoses and procedures coded. Directly consults with the professional staff for clarification of conflicting or ambiguous clinical data. Reports incorrect documentation or codes in the electronic patient health record.
Expertly searches the patient health record to find documentation justifying code assignment based on an expanded knowledge of the organization and structure of the patient record.
Uses a variety of window based applications in day to day activities and duties, such as Outlook, Excel, Word, and Access; competent in use of the health record applications (VistA and CPRS) as well as the encoder product suite.
#### Job family (Series)
0675 Medical Records Technician
Coders, Health Information
Health Information Coders
Medical Records Specialists
Medical Records Technicians
Specialists, Medical Records
Technicians, Medical Records
Conditions of Employment
You must be a U.S. Citizen to apply for this job
Designated and/or random drug testing may be required
Selective Service Registration is required for males born after 12/31/1959
You may be required to serve a probationary period
Subject to a background/security investigation
Must be proficient in written and spoken English
Must indicate month/year when listing employment history on resume
Must indicate full-time/part-time and number of hours worked when listing employment history on resume
* United States Citizenship: Non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy.
* Experience and Education
(1) Experience. One year of experience that indicates knowledge of medical terminology and general understanding of the health record. Six months of the required one year of experience must have provided the knowledge, skills and abilities (KSAs) needed to perform MRT work.
(2) Education. Two years above high school with a minimum of 12 semester hours directly related to MRT work (e.g., courses in medical terminology, anatomy & physiology, and introduction to health records).
(3) Experience/Education Combination. Equivalent combinations of experience and education are qualifying. The following educational/training substitutions are appropriate for combining education and experience:
(a) Six months of experience that indicates knowledge of medical terminology and general understanding of the health record and one year above high school with a minimum of 6 semester hours of health information technology courses.
(b) Successful completion of a course for medical technicians, hospital corpsmen, medical service specialists, or hospital training obtained in a training program given by the Armed Forces or the U.S. Maritime Service under close medical and professional supervision may be substituted on a month-for-month basis for up to six months of experience provided the training program included courses in anatomy, physiology, and medical record techniques and procedures. Also requires six additional months of experience that indicates knowledge of medical terminology and general understanding of the health record.
: GS-9 MRT (Coder) Clinical Documentation Improvement Specialist (CDIS)
(a) Experience. One year of experience equivalent to the next lower grade level.
(b) Demonstrated KSAs. In addition to the experience above, the candidate must demonstrate the following KSAs:
Knowledge of coding and documentation concepts, guidelines, and clinical terminology;
Ability to interpret and analyze all information in a patient's health record, including laboratory and other test results, to identify opportunities for more precise and/or complete documentation in the heath record;
Knowledge of anatomy and physiology, pathophysiology, and pharmacology;
Ability to establish and maintain strong verbal and written communication with providers;
Knowledge of regulations that define healthcare documentation requirements, including The Joint Commission, CMS, and VA guidelines;
Knowledge of coding rules and requirements to include clinical classification systems (such as current versions of ICD and CPT), complication or comorbidity/major complication or comorbidity (CC/MCC), Medicare Severity Diagnosis Related group (MS-DRG) structure, and Present on Admission (POA) indicators.
Knowledge of severity of illness and risk of mortality indicators; and
Knowledge of training methods and teaching skills sufficient to conduct continuing education for staff development. The training sessions may be technical in nature or may focus on teaching techniques for the improvement of clinical documentation issues.
(c) Assignment. CDISs are responsible for facilitating improved overall quality, education, and completeness and accuracy of medical record documentation as well as promoting appropriate clinical documentation through extensive interaction with physicians, other patient caregivers, HIM coding staff and other associated staff to ensure clinical documentation and services rendered to patients is complete and accurate for appropriate workload capture and resource allocations. Develop and/or update medical center policy memoranda pertaining to documentation improvement. Serve as technical expert in health record content and documentation requirements. Responsible for performing reviews of the health record documentation; developing criteria, collecting data, graphing and analyzing results, creating reports and communicating in writing and/or in person to appropriate leadership and groups. Obtain appropriate corrective action plans from responsible clinical services directors, when necessary, and recommend improvements or changes in documentation as deemed necessary. Adhere to established documentation requirements as outlined by accrediting agencies guidelines, regulations, policy and medical-legal requirements. Responsible for the development and implementation of active training/education programs (i.e. seminars, workshops, short courses, informational briefings, and conferences) for all providers to ensure the CDIS program objectives are met.
VA HANDBOOK 5005/79 SEPTEMBER 5, 2014 PART II APPENDIX G35
This vacancy is above the full performance level. For all assignments above the full performance level, the higher-level duties must consist of significant scope, complexity (difficulty), and range of variety, and be performed by the incumbent at least 25% of the time.
The work is mainly sedentary in nature in an office setting. Typically, the employee may sit to do the work, but there will be some walking, standing, bending and climbing step(s). There is also some carrying of patient records, classification and reference books, as well as record review supplies, weighing less than 15 lbs each.
A transcript must be submitted with your application if you are basing all or part of your qualifications on education.
Only education or degrees recognized by the U.S. Department of Education from accredited colleges, universities, schools, or institutions may be used to qualify for Federal employment. You can verify your education here: http://ope.ed.gov/accreditation/. If you are using foreign education to meet qualification requirements, you must send a Certificate of Foreign Equivalency with your transcript in order to receive credit for that education. For further information, visit: http://www.ed.gov/about/offices/list/ous/international/usnei/us/edlite-visitus-forrecog.html.
This job opportunity announcement may be used to fill additional vacancies.
Selected applicants will be required to complete an online onboarding process.
It is the policy of the VA to not deny employment to those that have faced financial hardships or periods of unemployment.
This position is in the Excepted Service and does not confer competitive status.
VA encourages persons with disabilities to apply. The health related positions in VA are covered by Title 38, and are not covered by the Schedule A excepted appointment authority.
Veterans and Transitioning Service Members: Please visit the VA for Vets site for career-search tools for Veterans seeking employment at VA, career development services for our existing Veterans, and coaching and reintegration support for military service members.
If you are unable to apply online view the following link for information regarding an Alternate Application.
Seasonal Influenza Prevention Program for VHA Health Care Personnel
Participation in the seasonal influenza program is a condition of employment and a requirement for all Department of Veterans Affairs Health Care Personnel (HCP). HCP are individuals who, during the influenza season, work in VHA locations where patients receive care or who come into contact with VA patients as part of their duties. VHA locations include, but are not limited to, VA hospitals and associated clinics, community living centers (CLCs), community-based outpatient clinics (CBOCs), domiciliary units, Vet centers and VA-leased facilities. HCP include all VA licensed and unlicensed, clinical and administrative, paid and unpaid, full- and part-time employees, intermittent employees, fee basis employees, VA contractors, students, researchers, volunteers, and trainees who work at these facilities.
How You Will Be Evaluated
You will be evaluated for this job based on how well you meet the qualifications above.
IN DESCRIBING YOUR EXPERIENCE, PLEASE BE CLEAR AND SPECIFIC. WE MAY NOT MAKE ASSUMPTIONS REGARDING YOUR EXPERIENCE.
Your application, résumé, C.V., and/or supporting documentation will be verified. Please follow all instructions carefully. Errors or omissions may affect consideration for employment.
The Professional Standards Board (a peer-review group) will review the selected candidate's education and experience and recommend the grade and salary at which the candidate will be placed. For internal selectees eligible for promotion, the board will determine grade and HR will determine step in accordance with policy.
Experience refers to paid and unpaid experience, including volunteer work done through National Service programs (e.g., Peace Corps, AmeriCorps) and other organizations (e.g., professional; philanthropic; religions; spiritual; community; student; social). Volunteer work helps build critical competencies, knowledge, and skills and can provide valuable training and experience that translates directly to paid employment. You will receive credit for all qualifying experience, including volunteer experience.
Background checks and security clearance
Public Trust - Background Investigation
To apply for this position, you must provide a complete Application Package which includes:
: Must include a listing of each job, starting/ending month of each work experience, work schedule (full-time or part-time) of each work experience, the facilities' full name and address, immediate supervisor's name, and a description of duties performed.
Copy of most recent SF-50 verifying your status as a current or past permanent Federal employee with reinstatement and/or transfer eligibility, if applicable.
VA Form 10-2850c:
Application for Associated Health Occupations can be found at: http://www.va.gov/vaforms/searchaction.asp?FormNo=2850&tkey;=&Action;=Search.
The following documents are accepted, and may be required if applicable to your eligibility and/or qualifications for this position. Please use this checklist to ensure you have included all documents required for your application, such as a copy of your transcript (if using education to qualify), SF-50's, documentation to support Veterans Preference or ICTAP/CTAP documentation (for displaced Federal employees).
When applying for Federal Jobs, eligible Veterans should claim preference for 5pt (TP), 10pt (CP/CPS/XP), or for Sole Survivor Preference (SSP) in the questionnaire. You must provide a legible copy of your DD214(s) which shows dates and character of service (honorable, general, etc.). If you are currently serving on active duty and expect to be released or discharged within 120 days you must submit documentation related to your active duty service which reflects the dates of service, character of service (honorable, general, etc.), and dates of impending separation. Additionally, disabled veterans and others eligible for 10-point preference (such as widows or mothers of eligible Veterans) must also submit an SF-15 Application for 10 Point Veteran Preference with required proof as stated on the form. Documentation is required to award preference. For more information on Veterans' Preference, please visit http://www.fedshirevets.gov/job/vetpref/index.aspx.
If you are relying on your education to meet qualification requirements:
Education must be accredited by an accrediting institution recognized by the U.S. Department of Education in order for it to be credited towards qualifications. Therefore, provide only the attendance and/or degrees from schools accredited by accrediting institutions recognized by the U.S. Department of Education.
Failure to provide all of the required information as stated in this vacancy announcement may result in an ineligible rating or may affect the overall rating.
A career with the U.S. Government provides employees with a comprehensive benefits package. As a federal employee, you and your family will have access to a range of benefits that are designed to make your federal career very rewarding. Learn more about federal benefits.
Review our benefits
Eligibility for benefits depends on the type of position you hold and whether your position is full-time, part-time, or intermittent. Contact the hiring agency for more information on the specific benefits offered.
How to Apply
How to Apply
All applicants are encouraged to apply online. To apply for this position, you must complete the full questionnaire and submit the documentation specified in the Required Documents section below. The complete application package must be submitted by 11:59 PM (ET) on 05/07/2018 to receive consideration.
To begin, click Apply Online to create a USAJOBS account or log in to your existing account. Follow the prompts to select your USA JOBS resume and/or other supporting documents and complete the occupational questionnaire.
Click Submit My Answers to submit your application package.
It is your responsibility to ensure your responses and appropriate documentation is submitted prior to the closing date.
To verify your application is complete, log into your USA JOBS account, https://my.usajobs.gov/Account/Login, select the Application Status link and then select the more information link for this position. The Details page will display the status of your application, the documentation received and processed, and any correspondence the agency has sent related to this application. Your uploaded documents may take several hours to clear the virus scan process. To return to an incomplete application, log into your USA JOBS account and click Update Application in the vacancy announcement. You must re-select your resume and/or other documents from your USA JOBS account or your application will be incomplete.
Agency contact information
Alexandria VA Medical Center
2495 Shreveport Highway
Learn more about this agency
Once your online application is submitted you will receive a confirmation notification by email. After we receive application packages (including all required documents) and the vacancy announcement closes, we will review applications to ensure qualification and eligibility requirements are met. After the review is complete, a referral certificate(s) is issued and applicants will be notified of their status by email. Referred applicants will be notified as such and may be contacted directly by the hiring office for an interview. All referred applicants receive a final notification once a selection decision has been made.
You may check the status of your application at any time by logging into your USA Jobs account and clicking on Applications. Information regarding your application status can be found in the USAJobs Help Center.
Fair & Transparent
Fair & Transparent
The Federal hiring process is setup to be fair and transparent. Please read the following guidance.
Equal Employment Opportunity Policy
The United States Government does not discriminate in employment on the basis of race, color, religion, sex (including pregnancy and gender identity), national origin, political affiliation, sexual orientation, marital status, disability, genetic information, age, membership in an employee organization, retaliation, parental status, military service, or other non-merit factor.
Equal Employment Opportunity (EEO) for federal employees & job applicants
Reasonable Accommodation Policy
Federal agencies must provide reasonable accommodation to applicants with disabilities where appropriate. Applicants requiring reasonable accommodation for any part of the application and hiring process should contact the hiring agency directly. Determinations on requests for reasonable accommodation will be made on a case-by-case basis.
A reasonable accommodation is any change to a job, the work environment, or the way things are usually done that enables an individual with a disability to apply for a job, perform job duties or receive equal access to job benefits.
Under the Rehabilitation Act of 1973, federal agencies must provide reasonable accommodations when:
An applicant with a disability needs an accommodation to have an equal opportunity to apply for a job.
An employee with a disability needs an accommodation to perform the essential job duties or to gain access to the workplace.
An employee with a disability needs an accommodation to receive equal access to benefits, such as details, training, and office-sponsored events.
You can request a reasonable accommodation at any time during the application or hiring process or while on the job. Requests are considered on a case-by-case basis.
Learn more about disability employment and reasonable accommodations or how to contact an agency.
Legal and regulatory guidance
Social security number request
Signature and false statements
New employee probationary period
This job originated on www.usajobs.gov. For the full announcement and to apply, visit www.usajobs.gov/GetJob/ViewDetails/496823600. Only resumes submitted according to the instructions on the job announcement listed at www.usajobs.gov will be considered.
Open & closing dates:
04/13/2018 to 05/07/2018
$50,598 to $65,778 per year
Pay scale & grade:
The Veterans Health Administration is home to the United States’ largest integrated health care system consisting of 152 medical centers, nearly 1,400 community-based outpatient clinics, community living centers, Vet Centers and Domiciliaries. Together these health care facilities and the more than 53,000 independent licensed health care practitioners who work within them provide comprehensive care to more than 8.3 million* Veterans each year.