Medical Records Technician (Clinical Documentation Improvement Specialist (CDIS - Inpatient))

About the role

This position is in the Health Information Management Service (HIMS) at James J. Peters VA Medical Center. The incumbent is responsible for reviewing the overall quality and completeness of clinical documentation. Applicants pending the completion of educational or certification/licensure requirements may be referred and tentatively selected but may not be hired until all requirements are met. Basic Requirements: United States Citizenship: Non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy. English Language Proficiency: MRTs (Coder) must be proficient in spoken and written English as required by 38 U.S.C. § 7403(f). Experience and Education: 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. (Note: Experience must be clearly demonstrated in resume to receive credit) 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); (Note: Must provide transcript to receive credit.) 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; (Note: Must provide transcript to receive credit.) 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: (Note: Experience must be clearly demonstrated in resume and must provide transcript to receive credit.) 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. 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). Certification: Persons hired or reassigned to MRT (Coder) positions in the GS-0675 series in VHA must have either below: Apprentice/Associate Level Certification through AHIMA or AAPC. Mastery Level Certification through AHIMA or AAPC. Clinical Documentation Improvement Certification through AHIMA or ACDIS. May qualify based on being covered by the Grandfathering Provision as described in the VA Qualification Standard for this occupation (only applicable to current VHA employees who are in this occupation and meet the criteria). Grade Determinations: In addition to the basic requirements for employment, candidates must meet the following grade-determining criteria for placement at grade levels specified. Medical Records Technician (Clinical Documentation Improvement Specialist (CDIS - Inpatient)), GS-9 Experience: One year of creditable experience equivalent to the journey grade level of a MRT (Coder-inpatient); (Note: Experience must be clearly demonstrated in resume to receive credit.) 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); (Note: Experience must be clearly demonstrated in resume and must provide transcript to receive credit.) OR, Mastery level certification through AHIMA or AAPC, and two years of experience in clinical documentation improvement; NOTE: See definitions below for a detailed definition of mastery level certification. (Note: Experience must be clearly demonstrated in resume to receive credit.) OR, Clinic