Veterans Health Administration Logo
Position Title
Medical Records Technician (Clinical Documentation Improvement Specialist (CDIS - Inpatient))
Agency
Veterans Health Administration
Announcement Number
CBST-12743690-25-TM Opens in new window
Open Period
Wednesday, June 4, 2025 to Monday, July 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.
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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.
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3. 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.
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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.
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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.
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 not include a photograph or video of yourself, or any sensitive information (age, date of birth, marital status, protected health information, religious affiliation, social security number, etc.) on your resume or cover letter. We will not access web pages or encrypted, and digitally signed documents linked on your resume or cover letter to determine your qualifications.
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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). (limit characters)
2. I authorize my application information being shared with hiring managers for similar positions. I understand this option may not result in further consideration for additional positions nor will it impact my application for this announcement. (limit characters)
Assessment 1
We will evaluate your resume, supporting documents, and responses to this Assessment Questionnaire to determine if you meet the eligibility and qualification requirements for this position. Your responses are subject to verification and must be supported by your resume and other application documents. You will not be contacted for missing information or documents. All information and documents are due at the time of application. (limit characters)
This section evaluates if you meet the basic requirements for the position of GS-0675 Medical Records Technician (Clinical Documentation Improvement Specialist (CDIS - Inpatient)) (limit characters)
Select “Yes” or “No” to the following question(s). (limit characters)
1. English Language: Candidates must be proficient in spoken and written English to be appointed as authorized by 38 U.S.C.? 7403(f). Are you proficient in basic written and spoken English? (limit characters)
2. Education and Experience: Please select from the Education and Experience listed below that best describes for qualifications for the Medical Records Technician (CDIS) position. (limit characters)
3. 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.
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GS 09 Grade Requirement: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; 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, candidates must demonstrate all of the following KSAs:
  • Knowledge of coding and documentation concepts, guidelines, and clinical terminology. ii.    
  • 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.
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4. Please select the appropriate answer below that best describes your experience that qualifies you for the GS-9 level. (limit characters)
Select “Yes” or “No” to the following question(s). (limit characters)
5. GS-09 Certification Requirement: 
Certification: Employees at this level must have either a mastery level certification or a clinical documentation improvement certification.

NOTE: Mastery Level Certification. This 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. Certification titles may change and certifications that meet the definition of mastery level certification may be added/removed by the above certifying bodies. However, 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. This 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. Certification titles may change, and certifications that meet the definition of clinical documentation improvement certification may be added/removed by the above certifying bodies. However, current Clinical Documentation Improvement Certifications include: Clinical Documentation Improvement Practitioner (CDIP) and Certified Clinical Documentation Specialist.

I can meet the certification requirements for a GS09 with either a mastery level certification or a clinical documentation improvement certification.
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