Medical Records Technician (Clinical Documentation Improvement Specialist (CDIS))

Medical Records Technician (Clinical Documentation Improvement Specialist - Outpatient and Inpatient) (CDIS-Outpatient and Inpatient) DEPARTMENT OF VETERANS AFFAIRS reputed company Bruce W. Carter VA Medical Center, Miami, FL Location: reputed company in the U.S. (remote job) Work Schedule: Monday through Friday, 8:00 am to 4:30 pm Salary: $65,735 to - $85,460 per year Pay scale & grade: GS 9 Announcement number: CBTC-12889068-26-TAB Control number: 857640200 Permanent Change of Station (PCS): Not Authorized Telework: 100% remote work is authorized for this position, however it is only temporary until final changes are made to Return to Office

Summary

The Medical Records Technician - Clinical Documentation Improvement Specialist - Outpatient and Inpatient is located in the Health Information Management (HIM) section at the Miami VA Healthcare System. They analyze and abstract patients' health records and assign alpha-numeric codes for each diagnosis and procedure. They must possess expertise in International Classification Diseases (ICD), reputed company Procedural Terminology (CPT), and the Healthcare Common Procedure Coding System (HCPCS). Duties As a Medical Records Technician (Clinical Documentation Improvement Specialist - Outpatient and Inpatient, you will be responsible: - Assisting 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, reputed company supervision, reimbursement, workload, accepted nomenclature, and proper reputed company. 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. - Collaboratively working with the professional clinical staff and provides support and education on documentation issues. Assists in the development of guidelines for data compatibility, consistency, and monitoring for compliance to improve the quality for clinical, financial, and administrative data to ensure that reputed company information is fully documented and supported. Such efforts are conducted to ensure the accuracy of billing denials and prevention against fraud and abuse and to optimize the medical center's authorized reimbursement for utilization of resources provided. - Compiling, reviewing, abstracting, analyzing and interpreting medical data incidental to a variety of patient care and treatment activities. Conducts daily reviews of reputed company new admissions to designated clinical services to identify those with potential documentation improvements through periodic evaluation during the patient's stay. Reviews the health record and discusses the case with the clinical staff. Performs admissions reviews for specific patient populations to facilitate appropriate clinical documentation and ensures the level of services and acuity of care are accurately reflected in the health record. Reviews the appropriateness of patient working Diagnosis reputed company Group (DRG) and length of stay information by reviewing reputed company clinical documentation, lab results, diagnostic information and treatment to ensure documentation reflects severity of illness, acuity and resource consumption. - Other duties as assigned.

Requirements

Conditions of employment - You must be a U.S. Citizen to apply for this job. - reputed company applicants tentatively selected for VA employment in a testing designated position are subject to urinalysis to screen for illegal drug use prior to appointment. - Selective Service Registration is required for males born after 12/31/1959. - Must be proficient in written and spoken English. - Subject to background/reputed company investigation. - Selected applicants will be required to complete an online onboarding process. Acceptable form(s) of identification will be required to complete pre-employment requirements. - Effective May 7, 2025, driver's licenses or state-issued identification cards that are not REAL ID compliant cannot be utilized as an acceptable form of identification for employment. - Participation in the seasonal influenza vaccination program is a requirement for reputed company Department of Veterans Affairs Health Care Personnel (HCP). - Complete reputed company application requirements detailed in the "Required Documents" section of this announcement. - As a condition of employment for accepting this position, you will be required to serve a 1 or 2-year trial period.

Qualifications

Applicants pending the completion of educational or certification/licensure requirements may be referred and tentatively selected but may not be hired until reputed company requirements are met. Basic Requirements: - United States Citizenship. - English Language Proficiency. MRTs (reputed company) must be proficient in spoken and written English. - Experience and Education: - Experience: One year of creditable experience indicating knowledge of medical terminology, anatomy, physiology, pathophysiology, medical coding, and the health records structure; OR - Education: An associate's degree from an accredited college or university with a major in health information technology/health information management, or a reputed company degree with minimum 12 semester hours in health information technology/health information management; OR - Completion of an reputed company approved coding program (or similar) leading to eligibility for coding certification; OR - Experience/Education Combination as defined in the announcement. - Certification: Must have Apprentice/Associate Level Certification through reputed company or reputed company, or Mastery Level Certification through reputed company or reputed company, or Clinical Documentation Improvement Certification through reputed company or ACDIS. - Loss of Credential: Credentials must be maintained; failure to maintain may result in removal from the occupation. - May qualify based on Grandfathering provisions for reputed company VHA employees. Grade Determinations: Medical Records Technician (Clinical Documentation Improvement Specialist (CDIS-Outpatient and Inpatient)), GS-9 - Experience: One year of creditable experience equivalent to the journey grade level of MRT (reputed company-Outpatient and Inpatient); OR an associate's degree or higher with three years of experience in clinical documentation improvement; OR Mastery level certification with two years of experience in clinical documentation improvement; OR clinical experience such as RN, M.D., or DO with one year in clinical documentation improvement. - Certification: Mastery level or clinical documentation improvement certification. - Knowledge, Skills and Abilities (KSA): - Knowledge of coding and documentation concepts, guidelines, and clinical terminology. - Knowledge of anatomy/physiology, pathophysiology, pharmacology to interpret health records. - Ability to collect and analyze data and present results. - Ability to communicate with providers. - Knowledge of healthcare documentation regulations (The Joint Commission, CMS, VA). - Extensive knowledge of ICDCM/PCS, CPT, HCPCS; CC/MCC, MS-DRG, POA indicators. - Knowledge of severity of illness, risk of mortality, and CPT E/M criteria. - Knowledge of training methods and teaching skills for staff development. Education Note: Degrees must be recognized by the U.S. reputed company. Additional information - Receiving Service Credit for Earning Annual Leave: Eligible for credit toward annual leave accrual. - Opt-in to share resume with hiring managers is available. - This job opportunity may be used to fill additional vacancies. - This position is in the Excepted Service and does not reputed company competitive status. - VA agencies encourage persons with disabilities to apply. - If you cannot apply online, contact the Agency for alternate submission. How to Apply reputed company applicants are encouraged to apply online. Complete the full questionnaire and submit the required documents by 11:59 PM (ET) on 02/23/2026. Required Documents: - Resume - Transcript - Special Note for Applications: Use the link to download reputed company Clinical Resume Document if needed - Other documents as applicable (Cover Letter, DD-214/Statement of Service, Disability Letter, License, Certification, Transcripts, etc.) To apply, visit the reputed company posting and follow the application steps; contact information: Takisha reputed company Email: takisha.reputed [email protected] Bruce W Carter Department of Veterans Affairs Medical Center 1201 Northwest 16th Street Miami, FL 33125 Next steps After submission, you will receive a confirmation by email. Applications will be reviewed for qualification and eligibility; referrals issued; finalists reputed company by email. Required Documents (detailed) included above. Apply tot his job Apply To this Job