Veterans Affairs, Veterans Health Administration MEDICAL RECORDS TECHNICIAN (CDIS), GS-09 in San Diego, California

Veterans Affairs, Veterans Health Administration
1 vacancy in the following location:
  • San Diego, CA
Work Schedule is Full Time - Permanent

Opened Friday 10/14/2016 (8 day(s) ago)

** Closes Monday 10/24/2016 (2 day(s) away)

Job Overview

Vacancy Identification Number (VIN): 1826351

OUR MISSION: To fulfill President Lincoln's promise – "To care for him who shall have borne the battle, and for his widow, and his orphan" – by serving and honoring the men and women who are America's Veterans. How would you like to become a part of a team providing compassionate care to Veterans?

VHA provides patient centered care, delivered by engaged, collaborative teams in an integrated environment that supports learning and continuous improvement. The Veteran's experience and health outcomes are improved with an emphasis on prevention through healing relationships in an optimal healing environment. We are seeking new team members interested in working in this environment. We are looking for team members that possess high energy, a strong work ethic, integrity, who are kind and empathetic, have a sense of humor, and who enjoy working for a collaborative, team-oriented system. The team member must be willing to build customer confidence by professional dress and demeanor. We invite you to apply to become part of a team of professionals engaged in promoting positive organizational change to improve business outcomes and create a positive healthcare experience for patients, families, and caregivers. As a VA professional, your opportunities are endless. With many openings in the multiple functions of VA, you will have a wide range of opportunities at your fingertips. Not only is it the largest, most technologically advanced integrated health care system in the nation, but we also provide many other services to Veterans through the Benefits Administration and National Cemeteries. VA professionals feel good about their careers and their ability to balance work and home life. VA offers generous paid time off and a variety of predictable and flexible scheduling opportunities. For more information on the Department of Veterans Affairs, go to

VA encourages persons with disabilities to apply. The health related positions in VA are covered by Title 38, and are not covered by the Schedule A excepted appointment authority.


The position is located in the Health Information Management Section (HIMS) of the Health Administration Service for the VA San Diego Healthcare System, Department of Veterans Affairs, in La Jolla, CA.**

The Medical Records Technician (Clinical Documentation Improvement Specialist (CDIS) is responsible for performing audits and analysis of medical documentation while providing ongoing education for the clinical and administrative staff throughout the Medical Center and the surrounding Community Based Outpatient Clinics (CBOCs).

Duties include but are not limited to:

  • Ensure active intra-departmental training program is in place for the medical records staff. Determines and meets training needs of extra-departmental professional, para-professional and non-professional personnel by originating training material, providing orientation to newly assigned interns and residents, participating in in-service programs conducted throughout the hospital.

  • Assists in the development of guidelines for data compatibility, consistency, and monitoring for compliance to improve the quality for clinical, financial, and administrative data to insure that all information is fully documented and supported to ensure the accuracy and quality of healthcare given, billing denials, prevention against fraud and abuse to maximize the medical center's authorized reimbursement for utilization of resources provided.

  • As technical expert in health information coding matters, provides advice and guidance on a medical records program(s) in relation to such issues as documentation requirements, liability issues, advance directives, informed consent, patient privacy and confidentiality, state reporting, etc.

  • Assists in writing coding protocol/policies which will reflect the required changes to enhance revenue through improved documentation.

  • Compiles, review, abstracts, analyzes and interprets medical data incidental to a variety of patient care and treatment activities. Conducts daily reviews of all new admissions to designated clinical services to identify those with potential documentation improvements through periodic evaluation during the patient's stay. Reviews the medical record and discusses the case with the clinical staff. Performs admission reviews for specific patient populations to facilitate appropriate clinical documentation and ensures the level of services and acuity of care are accurately reflected in the medical record. Reviews the appropriateness of patient working DRG and LOS information by reviewing all clinical documentation, lab results, diagnostic information and treatment to ensure documentation reflects severity of illness, acuity and resource consumption.

Work Schedule: Full Time; Monday – Friday 7:30 am – 4:00 pm

*Position Description Title/PD#: *Functional Statement: Clinical Documentation Specialist-Coding Professional

*A Recruitment or Relocation Incentive will not be authorized. *

Travel Required
  • Not Required
Relocation Authorized
  • No
Job Requirements
Key Requirements
  • Must pass pre-employment examination
  • Background and-or Security Investigation required
  • Selective Service Registration is required for males born after 12/31/1959.

*Basic Requirements: *

  • U.S. citizenship. Non-citizens may be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy.
  • Proficient in spoken and written English.

  • Physical Requirements. See VA Directive and Handbook 5019.

  • Experience and Education

(1) Experience.One year of experience that indicates knowledge of medical terminology and general understanding of the health record. Six months of the required one year of experience must have provided the knowledge, skills and abilities (KSAs) needed to perform MRT work.


(2) Education.Two years above high school with a minimum of 12 semester hours directly related to MRT work (e.g., courses in medical terminology, anatomy & physiology, and introduction to health records).


(3) Experience/Education Combination.Equivalent combinations of experience and education are qualifying. The following educational/training substitutions are appropriate for combining education and experience:

(a) Six months of experience that indicates knowledge of medical terminology and general understanding of 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 medical record techniques and procedures. Also requires six additional months of experience that indicates knowledge of medical terminology and general understanding of the health record.

Experience refers to paid and unpaid experience, including volunteer work done through National Service programs (e.g., Peace Corps, AmeriCorps) and other organizations (e.g., professional; philanthropic; religions; spiritual; community; student; social). Volunteer work helps build critical competencies, knowledge, and skills and can provide valuable training and experience that translates directly to paid employment. You will receive credit for all qualifying experience, including volunteer experience.

Grade Determinations:

In addition to the basic requirements for employment, the following criteria must be met when determining the grade of candidates.

*GS-9 MRT (Coder) Clinical Documentation Improvement Specialist (CDIS): *


One year of experience equivalent to the next lower grade level (GS-8) performing either inpatient or outpatient coding duties, or a combination of inpatient and outpatient coding duties. Inpatient duties consist of the performance of a comprehensive review of documentation within the health record to assign ICD codes for diagnosis, complications, co-morbid conditions, surgery, and procedures. Outpatient duties consist of the performance of a comprehensive review of documentation within the health record to accurately assign ICD codes for diagnosis and complications, and CPT codes for surgeries, procedures and evaluation, and management services. Directly consults with the professional staff for clarification of conflicting, incomplete or ambiguous clinical data in the health record. May be required to abstract and sequence codes into encoder software to obtain correct diagnosis-related group (DRG). Enters and corrects information that has been rejected, when necessary. Corrects any identified data errors or inconsistencies.

*Demonstrated KSAs. In addition to the experience above, the candidate must demonstrate the following KSAs: *

[1] Knowledge of coding and documentation concepts, guidelines, and clinical terminology.

[2] Ability 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 heath record.

[3] Knowledge of anatomy and physiology, pathophysiology, and pharmacology.

[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] Knowledge of coding rules and requirements to include clinical classification systems (such as current versions of ICD and CPT), complication or comorbidity/major complication or comorbidity (CC/MCC), Medicare Severity Diagnosis Related group (MS-DRG) structure, and Present on Admission (POA) indicators.

[7] Knowledge of severity of illness and risk of mortality indicators.

[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.


VA Handbook 5005, Part II, Appendix G35, Medical Record Technician Qualification Standard dated September 5, 2014.;=2

Note: Only education or degrees recognized by the U.S. Department of Education from accredited colleges, universities, schools, or institutions may be used to qualify for Federal employment. You can verify your education here: If you are using foreign education to meet qualification requirements, you must send a Certificate of Foreign Equivalency with your transcript in order to receive credit for that education.

Physical Requirements: Work is sedentary with the majority of the time spent sitting. The nature of the work is administrative in an office type setting working on a computer. Lifting and carrying (under 15 lbs) would be occasional but only in direct support of the administrative duties required by the nature of the work. The position requires periods of standing (2 hours), walking (2 hours), use of fingers and both hands.

Security Clearance

Not Applicable

Additional Information
What To Expect Next

After we receive application packages (including all required documents) and the vacancy announcement closes, we will review applications to ensure qualification and eligibility requirements are met. During our review, if your résumé and application package do not support your questionnaire answers, we will adjust your rating accordingly. After the review is complete, a referral certificate(s) is issued and applicants will be notified of their status by email (if provided); otherwise, applicants will receive a notification letter via the U.S. Postal Service. Referred applicants will be notified as such and may be contacted directly by the hiring office for an interview. All referred applicants receive a final notification once a selection decision has been made.

You may check the status of your application at any time by logging into your USAJOBS account and clicking on “Application Status.” For a more detailed update of your status, click on “more information.” Information regarding applicant notification points can be found in the USAJobs Resource Center.


VA offers a comprehensive benefits package. This link provides an overview of the benefits currently offered:

Other Information

It is the policy of the VA to not deny employment to those that have faced financial hardships or periods of unemployment.

This job opportunity announcement may be used to fill additional vacancies.

This position is in the Excepted Service and does not confer competitive status.

Salary Range: $53,413.00 to $69,432.00 / Per Year

Series & Grade: GS-0675-09/09

Supervisory Status: No

Who May Apply: All U.S. Citizens

Control Number: 453496100

Job Announcement Number: OP-16-AFM-1826351-BU