Medical Records Technician (Clinical Documentation Improvement Specialist-Inpatient/Outpatient)

About the role

This position is located in the Health Information Management (HIM) Section at the Tuscaloosa VA Medical Center and serves as a key member of the Medical Records Technician (MRT) team specializing in Clinical Documentation Improvement (CDI).

The Clinical Documentation Improvement Specialist plays a critical role in ensuring the accuracy, completeness, and integrity of the health record, directly supporting patient care, healthcare operations, compliance, and resource allocation.

What you will do

• Reviews inpatient and outpatient clinical documentation to ensure accuracy, completeness, and support of correct code assignment, severity of illness, and resource utilization.- Conducts concurrent and retrospective documentation reviews; identifies opportunities for clarification and improvement.
• Serves as a liaison between HIM and clinical providers, facilitating communication to improve documentation quality and compliance Queries clinicians to clarify ambiguous, incomplete, or conflicting documentation; evaluates responses for accuracy and compliance with coding and documentation standards.
• Provides focused education to providers on documentation requirements, E/M coding, CPT/ICD-10 specificity, and the impact of documentation on workload, quality measures, VERA, and reimbursement.
• Assists in developing, updating, and implementing policies and guidelines related to clinical documentation improvement.
• Reviews admissions, DRGs, treatment plans, lab results, and diagnostic data to verify documentation reflects patient acuity and clinical conditions.
• Participates in interdisciplinary rounds to offer guidance on documentation, coding rules, DRG methodology, and reimbursement considerations.
• Monitors trends or changes in industry standards, regulations, and coding guidance; identifies training needs and coordinates education with HIMS leadership and other stakeholders.
• Collaborates with Provider Auditor and HIMS leadership to ensure accurate provider documentation and compliance with regulatory and accreditation requirements.
• Maintains documentation review statistics, prepares summary reports, and analyzes data to identify trends, measure program effectiveness, and support leadership decision-making.
• Ensures provider documentation aligns with national guidelines, VA policy, UHDDS definitions, and ethical coding practices.
• Supports internal audits, compliance reviews, and process-improvement initiatives related to documentation, coding accuracy, and billing integrity.
• Provides technical expertise and guidance on health record documentation issues, including patient confidentiality, informed consent documentation, legal requirements, and record content standards.
• Contributes to staff training, orientation of new clinical providers, and intra-departmental education programs to strengthen documentation accuracy and quality.
• Performs other duties as assigned.
• Work Schedule: 8:00 a.m. - 4:30 p.m., Monday through Friday Telework: Not Authorized Virtual: This is not a virtual position.
• Functional Statement #: 63086F Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized

Requirements

• You must be a U.S. Citizen to apply for this job.
• To be considered for this position, you must complete all required steps in the process.
• In addition to the application and questionnaire, this position requires an online assessment.
• The online assessment measures critical general competencies required to perform the job.
• Selective Service Registration is required for males born after 12/31/1959.
• Must be proficient in written and spoken English.
• Subject to background/security investigation.
• Selected applicants will be required to complete an online onboarding process.
• Acceptable form(s) of identification will be required to complete pre-employment requirements (***).
• Effective May 7, 2025, driver's licenses or state-issued identification cards that are not REAL ID compliant cannot be utilized as an acceptable form of identification for employment.
• Participation in the seasonal influenza vaccination program is a requirement for all Department of Veterans Affairs Health Care Personnel (HCP).
• Complete all application requirements detailed in the "Required Documents" section of this announcement.
• As a condition of employment for accepting this position, you will be required to serve a 1 or 2-year trial period during which we will evaluate your fitness and whether your continued employment advances the public interest.
• In determining if your employment advances the public interest, we may consider: your performance and conduct; the needs and interests of the agency; whether your continued employment would advance organizational goals of the agency or the Government; and whether your continued employment would advance the efficiency of the Federal service.
• Upon completion of your trial period, your employment will be terminated unless you receive certification, in writing, that your continued employment advances the public interest.

Education

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. For further information, visit: ***

How you will be evaluated

IN DESCRIBING YOUR EXPERIENCE, PLEASE BE CLEAR AND SPECIFIC.

WE MAY NOT MAKE ASSUMPTIONS REGARDING YOUR EXPERIENCE.

Your application, resume, C.V., and/or supporting documentation will be verified. Please follow all instructions carefully. Errors or omissions may affect consideration for employment.

Your qualifications will be evaluated based on your application materials (e.g., resume, supporting documents), your responses on the application questionnaire, and your responses to all assessments required for this position.

You will be assessed on the following Competencies for this position: Attention to Detail Customer Service Decision Making Flexibility Integrity/Honesty Interpersonal Skills Learning Reading Comprehension Self-Management Stress Tolerance Teamwork 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.

The Department of Veterans Affairs performs pre-employment reference checks as an assessment method used in the hiring process to verify information provided by a candidate (e.g., on resume or during interview or hiring process); gain additional knowledge regarding a candidate's abilities; and assist a hiring manager with making a final selection for a position.

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

Veterans and Transitioning Service Members: Please visit the VA for Vets site for career-search tools for Veterans seeking employment at VA, career development services for our existing Veterans, and coaching and reintegration support for military service members.

Documents you must provide

• Long-form resume/Curriculum vitae (CV) Professional Certification Résumé.
• You are encouraged to build your resume using the Resume Builder on USAJobs.gov website, but if you choose to use your own résumé, then you must describe your job-related qualifications in detail that include beginning and ending dates (e.g. June 2007 to April 2009) for paid and non-paid work experience, hours worked per week, month and year of employment for each job title listed.
• Be sure that your resume clearly supports your work experience in detail.
• We cannot make assumptions regarding your qualifications.
• The following documents are accepted, and may be required if applicable to your eligibility and/or qualifications for this position.
• Please ensure you have included all documents required for your application, such as a copy of your transcript (if using education to qualify), SF-50's (current/former Federal employees), etc. DD-214/ Statement of Service Disability Letter (Schedule A) Disability Letter (VA) Long-form resume/Curriculum vitae (CV) PCS Orders Performance Appraisal Professional Certification Proof of Marriage Status Separation Notice (RIF) SF-15 SF-50/ Notification of Personnel Action Transcript Veterans' Preference: When applying for Federal Jobs, eligible Veterans should claim preference for 5pt (TP), 10pt (CP/CPS/XP), or for Sole Survivor Preference (SSP) in the questionnaire.
• You must provide a legible copy of your DD214(s) which shows dates and character of service (honorable, general, etc.).
• If you are currently serving on active duty and expect to be released or discharged within 120 days you must submit documentation related to your active duty service which reflects the dates of service, character of service (honorable, general, etc.), and dates of impending separation.
• Additionally, disabled veterans and others eligible for 10-point preference (such as widows or mothers of eligible Veterans) must also submit an SF-15 "Application for 10 Point Veteran Preference" with required proof as stated on the form.
• Documentation is required to award preference.
• For more information on Veterans' Preference, please visit Feds Hire Vets - Veterans - Job Seekers - Veterans' Preference.
• Veterans' preference does not apply for internal or other current permanent Federal agency employees.

What to expect next

Once your online application is submitted you will receive a confirmation notification by email. 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.

After the review is complete, a referral certificate(s) is issued and applicants will be notified of their status by email. 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 USA Jobs account and clicking on Applications. Information regarding your application status can be found in the USAJobs Help Center. NOTE: Participation in the seasonal influenza program is a condition of employment and a requirement for all Department of Veterans Affairs Health Care Personnel (HCP).

It is a requirement that all HCP to receive annual seasonal influenza vaccination or obtain an exemption for medical or religious reasons. Wearing a face mask is required when an exemption to the influenza vaccination has been granted. HCP in violation of this directive may face disciplinary action up to and including removal from federal service.

HCP are individuals who, during the influenza season, work in VHA locations or who come into contact with VA patients or other HCP as part of their duties. VHA locations include, but are not limited to, VA hospitals and associated clinics, community living centers (CLCs), community-based outpatient clinics (CBOCs), domiciliary units, Vet centers and VA-leased medical facilities.

HCP include all VA licensed and unlicensed, clinical and administrative, remote and onsite, paid and without compensation, full- and part-time employees, intermittent employees, fee basis employees, VA contractors, researchers, volunteers and health professions trainees (HPTs) who are expected to perform any or all of their work at these facilities.

HPTs may be paid or unpaid and include residents, interns, fellows and students. HCP also includes VHA personnel providing home-based care to Veterans and drivers and other personnel whose duties put them in contact with patients outside VA medical facilities.

Additional information

Under the Fair Chance to Compete Act, the Department of Veterans Affairs prohibits requesting an applicant's criminal history prior to accepting a tentative job offer. For more information about the Act and the complaint process, visit Human Resources and Administration/Operations, Security, and Preparedness (HRA/OSP) at The Fair Chance Act.

Reasonable Accommodation (RA) Requests: If you believe you have a disability (i.e., physical or mental), covered by the Rehabilitation Act of 1973 as amended that would interfere with completing the USA Hire Competency Based Assessments, you will be granted the opportunity to request a RA in your online application.

Requests for RA for the USA Hire Competency Based Assessments and appropriate supporting documentation for RA must be received prior to starting the USA Hire Competency Based Assessments. Decisions on requests for RA are made on a case-by-case basis.

If you meet the minimum qualifications of the position, after notification of the adjudication of your request, you will receive an email invitation to complete the USA Hire Competency Based Assessments, based on your adjudication decision.

You must complete all assessments within 48 hours of receiving the URL to access the USA Hire Competency Based Assessments if you received the link after the close of the announcement.

To determine if you need a RA, please review the Procedures for Requesting a Reasonable Accommodation for Online Assessments. During the application process you may have an option to opt-in to make your resume available to hiring managers in the agency who have similar positions.

Opting in does not impact your application for this announcement, nor does it guarantee further consideration for additional positions. This job opportunity announcement may be used to fill additional vacancies. This position is in the Excepted Service and does not confer competitive status.

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. If you are unable to apply online or need an alternate method to submit documents, please reach out to the Agency Contact listed in this Job Opportunity Announcement.