- Position Title
- Medical Records Technician (CDIS Inpatient)
- Agency
- Veterans Health Administration
- Announcement Number
- CBTC-12710062-25-JLC Opens in new window
- Open Period
- Monday, March 17, 2025 to Friday, April 11, 2025
For preview purposes only. To apply, please return to the USAJOBS announcement and click the Apply button.
Eligibilities
1.
Are you currently employed by the Department of Veterans Affairs?
This includes: Career/Career Conditional or Excepted Service (i.e. Canteen, Hybrid, Title 38, etc. and meets interchange agreement requirements). This does not include temporary, term or temporary intermittent.
To verify your eligibility, you must submit a copy of your most recent Notification of Personnel Action, Standard Form 50 (SF-50). Your SF-50 must include enough information to be able to determine that time-in-grade requirements have been met (if applicable) and include your position title, pay plan/series/grade, tenure and the type of appointment (i.e. Competitive or Excepted). Please be aware that award SF-50's do not always include this pertinent information.
This includes: Career/Career Conditional or Excepted Service (i.e. Canteen, Hybrid, Title 38, etc. and meets interchange agreement requirements). This does not include temporary, term or temporary intermittent.
To verify your eligibility, you must submit a copy of your most recent Notification of Personnel Action, Standard Form 50 (SF-50). Your SF-50 must include enough information to be able to determine that time-in-grade requirements have been met (if applicable) and include your position title, pay plan/series/grade, tenure and the type of appointment (i.e. Competitive or Excepted). Please be aware that award SF-50's do not always include this pertinent information.
2.
Are you an employee of the facility indicated for this position?
This includes: Career/Career Conditional or Excepted Service (i.e. Canteen, Hybrid, Title 38, etc. and meets interchange agreement requirements). This does not include temporary, term or temporary intermittent.
To verify your eligibility, you must submit a copy of your most recent Notification of Personnel Action, Standard Form 50 (SF-50). Your SF-50 must include enough information to be able to determine that time-in-grade requirements have been met (if applicable) and include your position title, pay plan/series/grade, tenure and the type of appointment (i.e. Competitive or Excepted). Please be aware that award SF-50's do not always include this pertinent information.
This includes: Career/Career Conditional or Excepted Service (i.e. Canteen, Hybrid, Title 38, etc. and meets interchange agreement requirements). This does not include temporary, term or temporary intermittent.
To verify your eligibility, you must submit a copy of your most recent Notification of Personnel Action, Standard Form 50 (SF-50). Your SF-50 must include enough information to be able to determine that time-in-grade requirements have been met (if applicable) and include your position title, pay plan/series/grade, tenure and the type of appointment (i.e. Competitive or Excepted). Please be aware that award SF-50's do not always include this pertinent information.
Preferences
1.
Which of the following items describes your current or recent (within the last five years) political appointee service?
If you responded yes to any of the items below, you will need to include a SF-50 specifying your prior service.
If you responded yes to any of the items below, you will need to include a SF-50 specifying your prior service.
Your resume must be submitted in English and include the following information for each job listed:
- Job title Duties (be as detailed as possible)
- Month & year start/end dates (e.g. June 2007 to April 2008)
- Full-time or part-time status (include hours worked per week)
- Series and Grade, if applicable, for all Federal positions you have held
- Please be aware that your answers will be verified against information provided on your resume. Be sure that your resume clearly supports your responses to all of the questions by addressing your work experience in detail.
By submitting your application, you are certifying, to the best of your knowledge and belief, all the information submitted by you with your application for employment is true, complete, and made in good faith, and that you have truthfully and accurately represented your work experience, knowledge, skills, abilities and education (degrees, accomplishments, etc.). The information you provide as part of your application may be investigated. You are also certifying, and acknowledging, that misrepresenting your experience or education, or providing false or fraudulent information in, or with your application, may affect your eligibility for appointment and/or continued employment. False or fraudulent statements may be punishable by fine or imprisonment (18 U.S.C. 1001).
If you are basing your qualifications on education (or a combination of education and experience) or if the position requires a college education to qualify, you must submit a copy of your transcripts with your application.
Assessment 1
Thank you for your interest in a Medical Record Technician (Clinical Documentation Improvement Specialist - Inpatient) position with our Bay Pines VA Healthcare System. We will evaluate your resume and your responses to this Assessment Questionnaire to determine if you qualified for this position. Your responses are subject to verification. Please review your responses for accuracy before you submit this questionnaire. Choose the one answer that best describes how you meet the qualification requirements for this position as described in the Qualifications Section of the Vacancy Announcement.
Full performance level for this position is GS-09.
Full performance level for this position is GS-09.
Select “Yes” or “No” to the following question(s).
1.
Certification. Employees at this level must have either a mastery level certification or a clinical documentation improvement certification.
Do you possess either a mastery level certification or a clinical documentation improvement certification?
- NOTE: Mastery Level Certification is considered a higher-level health information management or coding certification and is limited to certification obtained through AHIMA or AAPC. To be acceptable for qualifications, the specific certification must represent a comprehensive competency in the occupation. Stand-alone specialty certifications do not meet the definition of mastery level certification and are not acceptable for qualifications. Current mastery level certifications include: Certified Coding Specialist (CCS), Certified Coding Specialist - Physician-based (CCS-P), Registered Health Information Technician (RHIT), Registered Health Information Administrator (RHIA), Certified Professional Coder (CPC), Certified Outpatient Coder (COC), Certified Inpatient Coder (CIC). Clinical Documentation Improvement Certification is limited to certification obtained through AHIMA or the Association of Clinical Documentation Improvement Specialists (ACDIS). To be acceptable for qualifications, the specific certification must certify mastery in clinical documentation. Current Clinical Documentation Improvement Certifications include: Clinical Documentation Improvement Practitioner (CDIP) and Certified Clinical Documentation Specialist.
Do you possess either a mastery level certification or a clinical documentation improvement certification?
Loss of Credential. Following initial certification, credentials must be maintained through rigorous continuing education, ensuring the highest level of competency for employers and consumers. An employee in this occupation who fails to maintain the required certification must be removed from the occupation, which may result in termination of employment. At the discretion of the appointing official, an employee may be reassigned to another occupation for which he/she qualifies, if a placement opportunity exists.
Select “Yes” or “No” to the following question(s).
2.
English Language Proficiency. MRTs (Coder) must be proficient in spoken and written English as required by 38 U.S.C. ? 7403(f).
Are you proficient in spoken and written English?
Are you proficient in spoken and written English?
Grade Requirements for Medical Records Technician (CDIS Inpatient), GS-09
The following is used to determine if you meet the grade requirements for a Medical Records Technician (CDIS Inpatient) at the GS-09 level. Your responses are subject to verification and must be demonstrated in your resume. Please be as detailed as possible in your resume and ensure you demonstrate how you meet the specialized experience and/or knowledge, skills and abilities required for the position. No assumptions will be made
The following is used to determine if you meet the grade requirements for a Medical Records Technician (CDIS Inpatient) at the GS-09 level. Your responses are subject to verification and must be demonstrated in your resume. Please be as detailed as possible in your resume and ensure you demonstrate how you meet the specialized experience and/or knowledge, skills and abilities required for the position. No assumptions will be made
Select “Yes” or “No” to the following question(s).
3.
You must meet at least one of the following criteria to qualify for at the entry level for this position:
Do you meet one of the requirements listed above?
- (a) Experience: One year of creditable experience equivalent to the journey grade level (GS-08) of a MRT (Coder-inpatient). Examples of experience at GS-08 level include, but not limited to: comprehensive review of documentation within the health record to assign ICD codes for diagnosis, complications/major complications, comorbid/major comorbid conditions, surgery, and procedures for accurate assignment of diagnosis related groups (DRG), and/ or assigning CPT/HCPCS codes for inpatient professional services; independently reviews and abstracts clinical data from the record for documentation of diagnoses and procedures to ensure it is adequate and appropriate to support the assigned codes; codes all complicated and complex medical/specialty diseases processes, patient injuries, and all medical procedures in a wide range of inpatient settings and specialties; directly consults with the clinical staff for clarification of conflicting, incomplete, or ambiguous clinical data in the health record; abstracts, assigns, and sequence codes into encoder software to obtain correct DRG, support medical necessity, resolve encoder edits, and ensure codes accurately reflect services rendered; reviews provider health record documentation to ensure that it supports diagnostic and procedural codes assigned and is consistent with required medical coding nomenclature; enters and corrects information that has been rejected, when necessary; corrects any identified data errors or inconsistencies; ensures audit findings have been corrected and refiled; and uses various computer applications to abstract records, assign codes, and record and transmit data.
- (b) Holds an associate's degree or higher, and three years of experience in clinical documentation improvement (candidates must also have successfully completed coursework in medical terminology, anatomy and physiology, medical coding, and introduction to health records).
- (c) Holds a mastery level certification through AHIMA or AAPC, AND two years of experience in clinical documentation improvement.
- NOTE: Mastery Level Certification is considered a higher-level health information management or coding certification and is limited to certification obtained through AHIMA or AAPC. To be acceptable for qualifications, the specific certification must represent a comprehensive competency in the occupation. Stand-alone specialty certifications do not meet the definition of mastery level certification and are not acceptable for qualifications. Current mastery level certifications include: Certified Coding Specialist (CCS), Certified Coding Specialist - Physician-based (CCS-P), Registered Health Information Technician (RHIT), Registered Health Information Administrator (RHIA), Certified Professional Coder (CPC), Certified Outpatient Coder (COC), Certified Inpatient Coder (CIC).
- (d) Holds clinical experience such as RN, M.D., or DO, AND one year of experience in clinical documentation improvement.
Do you meet one of the requirements listed above?
4.
Demonstrated Knowledge, Skills, and Abilities. In addition to the experience and certification requirements listed above, the candidate must demonstrate all of the following KSAs:
Can you demonstrate the KSAs listed above? Be detailed in your resume as to how you meet these KSAs. No assumptions will be made.
- Knowledge of coding and documentation concepts, guidelines, and clinical terminology.
- Knowledge of anatomy and physiology, pathophysiology, and pharmacology in order 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 health record.
- Ability to collect and analyze data and present results in various formats, which may include presenting reports to various organizational levels.
- 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.
- Extensive knowledge of coding rules and regulations, to include current clinical classification systems such as ICD CM and PCS. They must also possess a knowledge of complication or comorbidity/major complication or comorbidity (CC/MCC), MS-DRG structure, and POA indicators.
- Knowledge of severity of illness, risk of mortality, and complexity of care.
- 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.
Can you demonstrate the KSAs listed above? Be detailed in your resume as to how you meet these KSAs. No assumptions will be made.
5.
Verification Statement - Select the appropriate answer to the statement below. Failure to provide an answer will result in your application not being considered for this position.
I certify that, to the best of my knowledge and belief, all of the information included in this questionnaire is true, correct, and provided in good faith. I understand that if I make an intentional false statement or commit deception or fraud in this application and its supporting materials, or in any document or interview associated with the examination process, I may be fined or imprisoned (18 U.S.C. 1001); my eligibilities may be cancelled; I may be denied an appointment; or I may be removed and debarred from Federal service (5 C.F.R. part 731). I understand that any information I give may be investigated and that responding "No" or providing no response to this item will result in my not being considered for this position.
I certify that, to the best of my knowledge and belief, all of the information included in this questionnaire is true, correct, and provided in good faith. I understand that if I make an intentional false statement or commit deception or fraud in this application and its supporting materials, or in any document or interview associated with the examination process, I may be fined or imprisoned (18 U.S.C. 1001); my eligibilities may be cancelled; I may be denied an appointment; or I may be removed and debarred from Federal service (5 C.F.R. part 731). I understand that any information I give may be investigated and that responding "No" or providing no response to this item will result in my not being considered for this position.
REMINDER - You must provide a complete application package which includes:
- Resume - Your resume must include the following information for each job listed:
- Job title and Grade Level (for Federal positions)
- Duties (be as detailed as possible and ensure they demonstrate how you meet the specialized experience and knowledge, skills and abilities required for the position)
- Month & year start/end dates (e.g. June 2007 to April 2008)
- Full-time or part-time status (include hours worked per week)
- If you are a current Federal Employee, you must submit a copy of your most recent SF-50 - Notification of Personnel Action (Not an award SF-50). You may need to submit more than one SF-50 to show you meet the time in experience for the grade being filled.
- Proof of current certification, licensure or registration (if applicable)