Clinical Documentation Improvement Specialist (Medical Records Technician / CDI)

Quick Facts

• Role: Medical Records Technician / Clinical Documentation Improvement Specialist (Outpatient/Inpatient)
• Schedule: Monday–Friday, 7:00am–3:30pm
• Work mode: Ad-hoc telework (not virtual)

Description

Ensures inpatient and outpatient documentation is accurate, complete, and supports proper code selection for high-quality healthcare data. You will collaborate with physicians and clinical staff through clarification and education, improving the specificity and completeness of documentation used for coding and reporting. The role also monitors documentation trends and missed opportunities to support outcomes and utilization accuracy.

Responsibilities

• Review clinical documentation quality and completeness for coding readiness and high-quality data.
• Use medical terminology, anatomy/physiology, disease processes, treatment modalities, diagnostic tests, medications, procedures, and health services principles to support code selection and reporting.
• Query clinical staff for clarification of ambiguous, conflicting, or incomplete documentation.
• Educate providers on documentation processes and the impact on coding, workload, quality measures, reimbursement, and funding.
• Educate on accurate and complete documentation for E/M, CPT, and ICD-10 specificity.
• Verify the most appropriate diagnosis, operation, procedure, ancillary, or E/M code using accepted guidelines and conventions.
• Review Veterans Equitable Resource Allocation (VERA) input on missed opportunities and coordinate provider education with the VERA Coordinator.
• Search the patient health record to locate evidence justifying code assignment.
• Use computer applications and electronic health record systems, plus encoder and/or CDI product suites.
• Support intra-departmental training for HIM staff and training needs for other personnel (orientation, interns/residents, in-services).
• Improve accuracy/completeness of documentation and support outcomes measurement through ongoing education and trend identification.
• Other duties as assigned.

Requirements

• U.S. citizenship
• Proficiency in written and spoken English
• Background/security investigation required
• Valid state driver’s license
• Complete online onboarding and pre-employment requirements
• Seasonal influenza vaccination program participation required
• Selective Service registration required for eligible males
• Basic qualification via required experience, associate degree (health information technology/management), or AHIMA-approved coding/intensive training leading to certification exam eligibility (or an equivalent combination)
• MRT (Coder) certification required through AHIMA/AAPC or CDI certification through AHIMA/ACDIS (as specified)
• GS-9 CDI qualification level per posting (CDI experience, education + CDI experience, mastery certification + CDI experience, or qualifying clinical background + CDI experience)
• At least one credential listed: CIC, CPC, CCS, CCS-P, CDEI, CDIP, RHIT, RHIA, CCDS, or CCDS-O

Benefits

• Paid Time Off: 37–50 days of annual paid time off per year (annual leave, sick leave, federal holidays)
• Parental leave: up to 12 weeks paid after 12 months of employment
• Child care subsidy: may be eligible after 60 days for up to 25% of eligible childcare costs (within stated limits)
• Retirement: traditional federal pension and federal 401K (up to 5% contribution)
• Insurance: federal health/vision/dental/term life/long-term care options
• Telework: ad-hoc (not virtual)