- Position Title
- Medical Records Technician (Clinical Documentation Improvement Specialist Inpatient)
- Agency
- Veterans Health Administration
- Announcement Number
- CBSY-12718414-25-BAD Opens in new window
- Open Period
- Friday, March 28, 2025 to Monday, April 7, 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.
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.
2.
Resume Reminder - Your resume must include the following information for each job listed:
Recommended: Even though we do not require a specific resume format, your resume must be clear so that we are able to fully evaluate your qualifications. To ensure you receive appropriate consideration, please list the duties you performed under each individual job title. If we are unable to match your experiences with the positions held, you may lose consideration for this vacancy. We cannot make assumptions regarding your qualifications.
Do you confirm that the above information is clearly stated for each work entry you are claiming experience for, and that each entry is full time unless otherwise annotated with part-time hours?
- Name and Contact Information
- Job title
- Duties (be as detailed as possible)
- Month & year start/end dates (e.g. June 2019 to April 2021)
- Full-time or part-time status (include hours worked per week if part-time)
- Series and Grade, if applicable, for all Federal positions you have held.
Recommended: Even though we do not require a specific resume format, your resume must be clear so that we are able to fully evaluate your qualifications. To ensure you receive appropriate consideration, please list the duties you performed under each individual job title. If we are unable to match your experiences with the positions held, you may lose consideration for this vacancy. We cannot make assumptions regarding your qualifications.
Do you confirm that the above information is clearly stated for each work entry you are claiming experience for, and that each entry is full time unless otherwise annotated with part-time hours?
If applying as an internal or status candidate with current or former Federal Service, you must provide a copy of your most recent non-award SF-50, "Notification of Personnel Action", showing the highest grade or promotion potential held, dated within the last year.
All qualifying experience you possess must be clearly described in your application package. We will not make assumptions when reviewing applications. Failure to demonstrate your experience and knowledge, skills, and abilities (KSAs) in your application may result in disqualification. It is strongly recommended that you write to each KSA to demonstrate how you have gained each one in your application package or on a supplemental document. Please see the announcement for KSA requirements.
Assessment 1
Select the appropriate answer to each of the following questions based on your current level of education and/or experience that demonstrates your ability to perform the duties of the position. When answering the questionnaire, remember that your experience and education are subject to verification by investigation. You may be asked to provide specific examples or documentation of experience or education as proof to support your answers, or you may be required to verify a response by a practical demonstration of your claimed ability to perform a task.
Select “Yes” or “No” to the following question(s).
1.
Basic Requirements: Select the appropriate answer to each of the following questions based on your current level of experience and/or education that demonstrates your ability to perform the duties of this position
.a. Citizenship. Citizen of the United States. (Non-citizens may be appointed when it is not possible to recruit qualified citizens in accordance with chapter 3, section A, paragraph 3g, this part.)
b. English Language Proficiency. MRTs (Coder) must be proficient in spoken and written English as required by 38 U.S.C. § 7403(f).
c. Experience and Education
(1) Experience. One year of creditable experience that indicates knowledge of medical terminology, anatomy, physiology, pathophysiology, medical coding, and the structure and format of a health records.
OR,
(2) Education. An associate's degree from an accredited college or university recognized by the U.S. Department of Education with a major field of study in health information technology/health information management, or a related degree with a minimum of 12 semester hours in health information technology/health information management (e.g., courses in medical terminology, anatomy and physiology, medical coding, and introduction to health records);
OR,
(3) Completion of an AHIMA approved coding program, or other intense coding training program of approximately one year or more that included courses in anatomy and physiology, medical terminology, basic ICD diagnostic/procedural, and basic CPT coding. The training program must have led to eligibility for coding certification/certification examination, and the sponsoring academic institution must have been accredited by a national U.S. Department of Education accreditor, or comparable international accrediting authority at the time the program was completed;
OR,
(4) Experience/Education Combination. Equivalent combinations of creditable experience and education are qualifying for meeting the basic requirements. The following educational/training substitutions are appropriate for combining education and creditable experience:
(a) Six months of creditable experience that indicates knowledge of medical terminology, general understanding of medical coding and 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 health record techniques and procedures. Also, requires six additional months of creditable experience that is paid or non-paid employment equivalent to a MRT (Coder).
Do you meet the these requirements?
.a. Citizenship. Citizen of the United States. (Non-citizens may be appointed when it is not possible to recruit qualified citizens in accordance with chapter 3, section A, paragraph 3g, this part.)
b. English Language Proficiency. MRTs (Coder) must be proficient in spoken and written English as required by 38 U.S.C. § 7403(f).
c. Experience and Education
(1) Experience. One year of creditable experience that indicates knowledge of medical terminology, anatomy, physiology, pathophysiology, medical coding, and the structure and format of a health records.
OR,
(2) Education. An associate's degree from an accredited college or university recognized by the U.S. Department of Education with a major field of study in health information technology/health information management, or a related degree with a minimum of 12 semester hours in health information technology/health information management (e.g., courses in medical terminology, anatomy and physiology, medical coding, and introduction to health records);
OR,
(3) Completion of an AHIMA approved coding program, or other intense coding training program of approximately one year or more that included courses in anatomy and physiology, medical terminology, basic ICD diagnostic/procedural, and basic CPT coding. The training program must have led to eligibility for coding certification/certification examination, and the sponsoring academic institution must have been accredited by a national U.S. Department of Education accreditor, or comparable international accrediting authority at the time the program was completed;
OR,
(4) Experience/Education Combination. Equivalent combinations of creditable experience and education are qualifying for meeting the basic requirements. The following educational/training substitutions are appropriate for combining education and creditable experience:
(a) Six months of creditable experience that indicates knowledge of medical terminology, general understanding of medical coding and 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 health record techniques and procedures. Also, requires six additional months of creditable experience that is paid or non-paid employment equivalent to a MRT (Coder).
Do you meet the these requirements?
2.
Certification: Persons hired or reassigned to MRT (Coder) positions must be certified.
a) Apprentice/Associate Level Certification through AHIIMA or AAPC.
b) Mastery Level Certification through AHIMA or AAPC.
c) Clinical Documentation Improvement Certification through AHIMA or AAPC.
Do you have one of the following certificates?
NOTE: Mastery level certification is required for all positions above the journey level; however, for clinical documentation improvement specialist assignments, a clinical documentation improvement certification may be substituted for a mastery level certification
a) Apprentice/Associate Level Certification through AHIIMA or AAPC.
b) Mastery Level Certification through AHIMA or AAPC.
c) Clinical Documentation Improvement Certification through AHIMA or AAPC.
Do you have one of the following certificates?
NOTE: Mastery level certification is required for all positions above the journey level; however, for clinical documentation improvement specialist assignments, a clinical documentation improvement certification may be substituted for a mastery level certification
3.
GS-9 Specialized Experience: Do you have one year of creditable experience equivalent to the journey grade level (GS-8) MRT Coder?
Do you possess 1 year of specialized equivalent to the above?
- Ability to analyze the health record to identify all pertinent diagnoses and procedures for coding and to evaluate the adequacy of the documentation. This includes the ability to read and understand the content of the health record, the terminology, the significance of the comments, and the disease process/pathophysiology of the patient.
- Ability to accurately perform the full scope of outpatient coding, including ambulatory surgical cases, diagnostic studies and procedures, and outpatient encounters, and inpatient facility coding, including inpatient discharges, surgical cases, diagnostic studies and procedures, and inpatient professional services.
- Skill in interpreting and adapting health information guidelines that are not completely applicable to the work, or have gaps in specificity, and the ability to use judgment in completing assignments using incomplete or inadequate guidelines
Do you possess 1 year of specialized equivalent to the above?
4.
Medical Records Technician (Clinical Documentation Improvement Specialist (CDIS- Inpatient)), GS-9
In an addition to one year of specialized experience you must demonstrate all of the following:
(a) Experience. One year of creditable experience equivalent to the journey grade level of a MRT (Coder-Outpatient and Inpatient);
OR,
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);
OR,
Mastery level certification through AHIMA or AAPC and two years of experience in clinical documentation improvement;
OR,
Clinical experience such as RN, M.D., or DO, and one year of experience in clinical documentation improvement.
Demonstrated Knowledge, Skills, and Abilities. In addition to the experience above, the candidate must demonstrate all of the following KSAs:
Do you possess all of the above?
In an addition to one year of specialized experience you must demonstrate all of the following:
(a) Experience. One year of creditable experience equivalent to the journey grade level of a MRT (Coder-Outpatient and Inpatient);
OR,
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);
OR,
Mastery level certification through AHIMA or AAPC and two years of experience in clinical documentation improvement;
OR,
Clinical experience such as RN, M.D., or DO, and one year of experience in clinical documentation improvement.
Demonstrated Knowledge, Skills, and Abilities. In addition to the experience above, the candidate must demonstrate all of the following KSAs:
- Knowledge of coding and documentation concepts, guidelines, and clinical terminology.
- Knowledge of anatomy and physiology, pathophysiology, and pharmacology 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 ICDCM and PCS, CPT, and HCPCS. They must also possess 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, complexity of care for inpatients, and CPT Evaluation and Management (E/M) criteria to ensure the correct selection of E/M codes that match patient type, setting of service, and level of E/M service provided for outpatients.
- 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.
Do you possess all of the above?
RESUME REMINDER - Your resume must include the following information for each job listed: * Job Title and a summary of duties. (be as detailed as possible) * Month & year start/end dates (e.g. June 2007 to April 2008) * Full-time or part-time status (MUST include hours worked per week if part-time). * Be sure that your resume clearly supports your responses to all of the questions by addressing your work experience in detail. * Recommended: Even though we do not require a specific resume format, your resume must be clear so that we are able to fully evaluate your qualifications. To ensure you receive appropriate consideration, please list the duties you performed under each individual job title. If we are unable to match your experiences with the positions held, you may lose consideration for this vacancy. We cannot make assumptions regarding your qualifications.
SF-50 (Notice of Personnel Action). *To demonstrate you are a current or former Federal employee, you must provide your most recent SF-50 (dated with in the year). *To demonstrate time-in-grade eligibility you must submit SF-50s that sufficiently indicates you meet the time-in-grade requirement. If your most recent SF-50 has an effective date within the past year, it may not clearly demonstrate you possess one-year time-in-grade, as required by the announcement. In this instance, you must provide an additional SF-50 that clearly demonstrates one-year time-in-grade. Award 50s do not provide sufficient information and will not be accepted. Examples of appropriate SF-50s include: * Within grade increases at the highest grade held; or * Promotions with an effective date more than one year old; or * SF-50s at the highest grade held with an effective date more than one year old.
SF-50 (Notice of Personnel Action). *To demonstrate you are a current or former Federal employee, you must provide your most recent SF-50 (dated with in the year). *To demonstrate time-in-grade eligibility you must submit SF-50s that sufficiently indicates you meet the time-in-grade requirement. If your most recent SF-50 has an effective date within the past year, it may not clearly demonstrate you possess one-year time-in-grade, as required by the announcement. In this instance, you must provide an additional SF-50 that clearly demonstrates one-year time-in-grade. Award 50s do not provide sufficient information and will not be accepted. Examples of appropriate SF-50s include: * Within grade increases at the highest grade held; or * Promotions with an effective date more than one year old; or * SF-50s at the highest grade held with an effective date more than one year old.