Clinical Documentation Integrity Specialist (Medical Records Technician)

Quick Facts

• Role: Clinical Documentation Integrity Specialist (Medical Records Technician / MRT Coder) for outpatient and inpatient documentation integrity

• Schedule: Monday–Friday, 7:00am–3:30pm

• Telework: Ad-hoc (not a virtual position)

Description

Review and improve the quality and completeness of clinical documentation to ensure it supports proper code selection and accurate reporting for high-quality healthcare data. Work with clinical staff to request clarifications, educate providers on documentation processes (including E/M, CPT, and ICD-10 specificity), and support accurate coding for inpatient and outpatient episodes of care.

Responsibilities

• Verify the most appropriate diagnosis, operation, procedure, ancillary, and E/M codes using accepted coding practices and conventions

• Collaborate with physicians and care teams through written, verbal, or electronic clarification requests

• Provide provider education on documentation processes and the impact on coding, workload, quality measures, reimbursement, and funding

• Review Veterans Equitable Resource Allocation (VERA) missed opportunities and coordinate documentation education with the VERA Coordinator

• Search and abstract the patient record to find documentation justifying code assignment with high specificity

• Support and deliver training for HIM staff; assess training needs for other personnel and participate in inservice programs

• Monitor and improve documentation accuracy and completeness for measuring and reporting outcomes

• Identify trends/opportunities to improve clinical documentation

• Develop guidance for documentation data compatibility/consistency and support compliance to prevent billing denials, fraud, and abuse

• Serve as a technical expert for documentation-related requirements (e.g., liability, advance directives, informed consent, privacy/confidentiality)

• Recommend documentation process improvements and policy updates as needed

• Compile, review, abstract, and analyze medical data related to patient care and treatment activities

Requirements

• U.S. citizenship

• Selective Service registration (for males born after 12/31/1959)

• Proficiency in written and spoken English

• Subject to background/security investigation

• Valid state driver’s license

• Complete VA online onboarding and pre-employment requirements

• Participate in the seasonal influenza vaccination program

• Meet basic qualifications: 1 year qualifying experience in medical terminology/anatomy/physiology/pathophysiology and medical coding/health record structure OR an associate degree OR AHIMA/AAPC-approved (or comparable) intensive coding training OR an approved combination of education and experience

• Obtain required MRT (Coder) certification via AHIMA/AAPC (Apprentice/Associate or Mastery) or Clinical Documentation Improvement certification (AHIMA or ACDIS)

• For GS-9/CDIS: meet the specified GS-9 determination requirements (experience/education/certification) and perform MRT duties as part of the higher-level scope (at least 25% of the time)

• Preferred: at least one of CIC, CPC, CCS, CCS-P, CDEI, CDIP, RHIT, RHIA, CCDS, CCDS-O

Benefits

A comprehensive federal benefits package is available; eligibility depends on the position type and schedule.