- Position Title
- Medical Records Technician (CDIS Inpat) Internal
- Agency
- Veterans Health Administration
- Announcement Number
- CBTD-12720991-25-MN Opens in new window
- Open Period
- Wednesday, May 28, 2025 to Thursday, June 12, 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.
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).
2.
In accordance with 38 U.S.C. 7402(d), No person shall serve in direct patient care positions unless they are proficient in basic written and spoken English. Are you proficient in basic written and spoken English?
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
Please 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 this 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.
Please be sure to submit all the supporting documents as they apply to your eligibility and qualifications. The checklist for the supporting documents can also be found in the Required Documents section of the vacancy announcement.
Please be sure to submit all the supporting documents as they apply to your eligibility and qualifications. The checklist for the supporting documents can also be found in the Required Documents section of the vacancy announcement.
Please provide the following information regarding your clinical documentation improvement certification obtained through AHIMA or the Association of Clinical Documentation Improvement Specialists (ACDIS)
Name of Institution:
Certification Number:
Name of Institution:
Certification Number:
Select “Yes” or “No” to the following question(s).
1.
Citizenship: Are you a Citizen of the Unites 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.)
(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.)
2.
Basic Requirement:
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 4 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).
One year of creditable experience equivalent to the journey grade level of MRT (Coder-inpatient);
OR,
An associate degree or higher, and three years of experience in clinical documentation improvement that indicates knowledge of medical terminology, anatomy, physiology, pathophysiology, medical coding, and the structure and format of a 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.
Do you possess one or more of the types of experiences listed above?
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 4 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).
One year of creditable experience equivalent to the journey grade level of MRT (Coder-inpatient);
OR,
An associate degree or higher, and three years of experience in clinical documentation improvement that indicates knowledge of medical terminology, anatomy, physiology, pathophysiology, medical coding, and the structure and format of a 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.
Do you possess one or more of the types of experiences listed above?
3.
Certification:
Employees at this level must have Clinical Documentation Improvement Certification obtained through AHIMA or the Association of Clinical Documentation Improvement Specialists (ACDIS).
Do you possess this certification?
Employees at this level must have Clinical Documentation Improvement Certification obtained through AHIMA or the Association of Clinical Documentation Improvement Specialists (ACDIS).
Do you possess this certification?
4.
Medical Records Technician (Clinical Documentation Improvement Specialist (CDIS - Inpatient)
(a) Experience. One year of creditable experience equivalent to the journey grade level of a MRT (Coder-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;
NOTE: See paragraph 2g above for a detailed definition of mastery level certification.
OR,
Clinical experience such as RN, M.D., or DO, and one year of experience in clinical documentation improvement.
Do you possess one or more of the types of experiences listed above?
(a) Experience. One year of creditable experience equivalent to the journey grade level of a MRT (Coder-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;
NOTE: See paragraph 2g above for a detailed definition of mastery level certification.
OR,
Clinical experience such as RN, M.D., or DO, and one year of experience in clinical documentation improvement.
Do you possess one or more of the types of experiences listed above?
5.
Demonstrated Knowledge, Skills, and Abilities (KSA's): addition to the experience above, the candidate must demonstrate all of the following
1. Knowledge of coding and documentation concepts, guidelines, and clinical terminology.
2. 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.
3. Ability to collect and analyze data and present results in various formats, which may include presenting reports to various organizational levels.
4. Ability to establish and maintain strong verbal and written communication with providers.
5. Knowledge of regulations that define healthcare documentation requirements, including The Joint Commission, CMS, and VA guidelines.
6. 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 comorbility (CC/MCC), MSDRG structure, and POA indicators.
7. Knowledge of severity of illness, risk of mortality, and complexity of care.
8. 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 above KSA's?
1. Knowledge of coding and documentation concepts, guidelines, and clinical terminology.
2. 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.
3. Ability to collect and analyze data and present results in various formats, which may include presenting reports to various organizational levels.
4. Ability to establish and maintain strong verbal and written communication with providers.
5. Knowledge of regulations that define healthcare documentation requirements, including The Joint Commission, CMS, and VA guidelines.
6. 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 comorbility (CC/MCC), MSDRG structure, and POA indicators.
7. Knowledge of severity of illness, risk of mortality, and complexity of care.
8. 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 above KSA's?
SF-50 REMINDER: If you are claiming eligibility as a current federal employee, your SF-50, Notice of Personnel Action must be uploaded with your application. Award 50's do not provide sufficient information and will not be accepted for the purpose of verifying time-in-grade. Examples of appropriate SF-50's include: Within grade increases at the highest grade held; or Promotions with an effective date more than one year old; or SF-50's at the highest grade held with an effective date more than one year old.
RESUME REMINDER: Your resume must include the following information each job listed: Job title Duties (be as detailed as possible) Month & year start/end dates (e.g. June 2017 to April 2018) Full-time or part-time status (include hours worked per week) 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. 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.
EDUCATION REMINDER: If you are using education or training to qualify for this position, you MUST upload/submit supporting documentation (i.e. transcripts, certificate of completion of training). Failure to do so will make you ineligible for consideration.
RESUME REMINDER: Your resume must include the following information each job listed: Job title Duties (be as detailed as possible) Month & year start/end dates (e.g. June 2017 to April 2018) Full-time or part-time status (include hours worked per week) 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. 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.
EDUCATION REMINDER: If you are using education or training to qualify for this position, you MUST upload/submit supporting documentation (i.e. transcripts, certificate of completion of training). Failure to do so will make you ineligible for consideration.