- Position Title
- Medical Records Technician (CDIS)
- Agency
- Veterans Health Administration
- Announcement Number
- OCA-FY25-688-CDIS-SR Opens in new window
- Open Period
- Wednesday, May 7, 2025 to Friday, November 7, 2025
For preview purposes only. To apply, please return to the USAJOBS announcement and click the Apply button.
Eligibilities
1.
Are you a current or former federal employee displaced from the agency hiring for this position? If yes, confirm:
For more information, review the USAJOBS Help Center.
To verify your eligibility, you must submit supporting documentation such as a Reduction in Force (RIF) separation notice or a Proposed Removal/Separation notice to include your latest performance rating (if the notice does not have this information included, you must submit a copy of your most recent performance appraisal) and a copy of your latest Notification of Personnel Action, Standard Form 50.
- you are located in the same local commuting area of the vacancy; AND,
- you are applying to a position that is at or below the grade level of the position from which you were or will be separated; AND,
- your grade is equivalent to or below the grade level of the vacancy; AND,
- your last performance rating of record is at least fully successful or the equivalent.
For more information, review the USAJOBS Help Center.
To verify your eligibility, you must submit supporting documentation such as a Reduction in Force (RIF) separation notice or a Proposed Removal/Separation notice to include your latest performance rating (if the notice does not have this information included, you must submit a copy of your most recent performance appraisal) and a copy of your latest Notification of Personnel Action, Standard Form 50.
2.
Are you a Veterans Health Administration employee?
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.
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.
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).
Assessment 1
Select “Yes” or “No” to the following question(s).
1.
Basic Requirement - Citizenship.
Are you a Citizen or Naturalized Citizen of the United States?
Are you a Citizen or Naturalized Citizen of the United States?
2.
Basic Requirement - English Language Proficiency.
Are you proficient in spoken and written English?
Are you proficient in spoken and written English?
3.
Basic Requirement - Experience and Education.
Do you have one of the following:
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,
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,
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;
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 have one of the following:
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,
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,
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;
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).
4.
Basic Requirement - Certification.
Do you possess any of the three below certifications?
Certification. Persons hired or reassigned to MRT (Coder) positions in the GS-0675 series in VHA must have either (1), (2), or (3) below:
(1) Apprentice/Associate Level Certification through AHIMA or AAPC.
(2) Mastery Level Certification through AHIMA or AAPC.
(3) Clinical Documentation Improvement Certification through AHIMA or ACDIS. 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.
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.
Do you possess any of the three below certifications?
Certification. Persons hired or reassigned to MRT (Coder) positions in the GS-0675 series in VHA must have either (1), (2), or (3) below:
(1) Apprentice/Associate Level Certification through AHIMA or AAPC.
(2) Mastery Level Certification through AHIMA or AAPC.
(3) Clinical Documentation Improvement Certification through AHIMA or ACDIS. 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.
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.
5.
Please list your Certification(s) number(s), and the expiration date(s).
Select “Yes” or “No” to the following question(s).
6.
Basic Requirement - Physical Requirements.
Are you physically, mentally, and emotionally fit to perform the duties of a Medical Records Technician - Clinical Documentation Improvement Specialist (CDIS) - (Inpatient/Outpatient)?
Are you physically, mentally, and emotionally fit to perform the duties of a Medical Records Technician - Clinical Documentation Improvement Specialist (CDIS) - (Inpatient/Outpatient)?
7.
Specialized Experience - GS-9 Medical Records Technician (Clinical Documentation Improvement Specialist) (CDIS) (Outpatient and Inpatient)
- One year of creditable experience equivalent to the journey grade level (GS-8) of a MRT (Coder-Outpatient)*;
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 the definitions section of this standard (paragraph 2g above) for a detailed definition of mastery level certification.
OR,
- Clinical experience, such as Registered Nurse (RN), Medical Doctor (M.D.), or Doctor of Osteopathy (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 have one of the above-listed requirements and knowledge, skills, and abilities?
Select “Yes” or “No” to the following question(s).
8.
Advanced Certification.
Do you possess either a mastery level certification or a Clinical Document Improvement Certification through AHIMA or AAPC.?
Do you possess either a mastery level certification or a Clinical Document Improvement Certification through AHIMA or AAPC.?
9.
Please list whether you possess a mastery level certification or a Clinical Document Improvement Certification and provide the certification number and expiration date.
Resume Reminder:
Your resume must include the following information for each job listed:
Job title Duties (be as detailed as possible)
Month & Year start/end dates (e.g. June 2019 to April 2020)
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.
In addition, please be sure to include your Education, Residency program to include Month and year start/end dates, and license, certification, or registration information to include the state, territory, or Commonwealth, license, certification, and/or registration number, and Month, Day, and Year of expiration. We cannot make assumptions regarding your qualifications.
Helpful training links:
https://www.youtube.com/watch?v=-XeSxzezvY8 Applying to federal jobs and how it works
https://www.youtube.com/watch?v=HY5Z_pfFUK4 Looking for jobs and applying to Fed jobs
https://www.youtube.com/watch?v=1-fYgeDJpYI The Federal Employment Process: Resources and Frequently Asked
Your resume must include the following information for each job listed:
Job title Duties (be as detailed as possible)
Month & Year start/end dates (e.g. June 2019 to April 2020)
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.
In addition, please be sure to include your Education, Residency program to include Month and year start/end dates, and license, certification, or registration information to include the state, territory, or Commonwealth, license, certification, and/or registration number, and Month, Day, and Year of expiration. We cannot make assumptions regarding your qualifications.
Helpful training links:
https://www.youtube.com/watch?v=-XeSxzezvY8 Applying to federal jobs and how it works
https://www.youtube.com/watch?v=HY5Z_pfFUK4 Looking for jobs and applying to Fed jobs
https://www.youtube.com/watch?v=1-fYgeDJpYI The Federal Employment Process: Resources and Frequently Asked