Veterans Affairs, Veterans Health Administration CLINICAL DOCUMENTATION IMPROVEMENT SPECIALIST (MEDICAL RECORDS TECHNICIAN) in Martinez, California

Veterans Affairs, Veterans Health Administration
1 vacancy in the following locations:
  • Martinez, CA
  • Sacramento, CA
Work Schedule is Full Time - Excepted Service Permanent

Opened Friday 10/14/2016 (7 day(s) ago)

** Closes Friday 10/28/2016 (7 day(s) away)

Job Overview

Vacancy Identification Number (VIN): 1826271

There is one vacancy for this position; the duty station can be at Mather or Martinez

Recruitment/Relocation incentive may be authorized for a highly qualified candidate

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.

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 and leadership positions 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.


MEDICAL RECORDS TECHNICIAN (Coder – Clinical Documentation Improvement Specialist)

The incumbent acts independently to plan, organize, direct and control areas with emphasis on data validation, analysis and generation of reports associated with the facility’s Health Information Management program. Assures CPT/HCPCS and ICD-9-CM and/or ICD-10-CM/PCS codes, DRGs, and APGs are supported by clinical and physician documentation for accurate and reliable data collection and reimbursement. Collaboratively works with the professional clinical staff and outside agencies. The duties include, but are not limited to:

  • Provides support and education on documentation issues and assists in the development of guidelines for data compatibility, consistency and monitoring to improve the quality of clinical, financial and administrative data to ensure that every part of the information is completely documented and supported.

  • Ensure coded data accurately reflects service provided, based on documentation, prevention against fraud and abuse, and that the facility receives the most appropriate level of reimbursement and allocation.

  • Provides technical staff support for the administration of the medical center’s Health Information Management program.

  • Reviews reports of unsigned progress note cases, makes appropriate adjustments, and provides technical advice and support regarding the repair of discrepancies in the documentation or the processing of billable encounters.

  • Assists the healthcare team in coding with the highest degree of accuracy.

  • Completes a monthly Reasons Not Billable Review and monthly Coding Audits of provider documentation for coding accuracy and documentation specificity. These findings are reported to the Coding Supervisor and Compliance Committee.

  • Develops and coordinates internal monitoring to oversee quality and education with documentation, HIMS, coding and billing issues.

  • Generates, analyzes, validates, and presents reports to the Chief, HIMS and committees as needed.

  • Coordinates and assists in the development of standardized, system-wide guidelines, procedures and education materials for coding and abstracting to meet the rules and regulations of governmental health programs, VA, and other external entity requirements and payers.

  • Researches the impact of coding changes and issues coding alerts addressing concerns, target areas, etc.

Work Schedule: Monday – Friday; hours negotiable

Position Description Title/PD#:Medical Records Technician (Coder – Clinical Documentation Improvement Specialist)

Rotating Shift:No

Required to work Holidays and/or Weekends: No

Fair Labor Standards Act (FLSA):Non-Exempt

Bargaining Unit Position:Yes

Recruitment/Relocation Incentive: Recruitment/Relocation incentive may be authorized for a highly qualified candidate.

Travel Required
  • Occasional Travel
  • To Other NCHCS Sites
Relocation Authorized
  • No
Job Requirements
Key Requirements
  • Must pass pre-employment examination
  • Must be proficient in written and spoken English
  • Background and-or Security Investigation required
  • Selective Service Registration is required for males born after 12/31/1959.


  • Citizenship– Must be a citizen of the United States.

  • English Language Proficiency – Must be proficient in spoken and written English.

SPECIALIZED EXPERIENCE:Must have at least one year of specialized experience equivalent to the GS-8 grade level that equipped you with the particular knowledge, skills, and abilities to perform successfully the duties of this position. Examples of specialized experience may include: analyzes the medical record to identify all pertinent diagnoses and procedures for coding, and to evaluate the adequacy of the documentation; performs the full scope of outpatient coding including ambulatory surgical cases, diagnostic studies and procedures, and outpatient encounters, and/or inpatient coding, including discharges, surgical cases, and inpatient professional fees; and interprets health information guidelines and uses judgment in completing assignments.

There is no educational substitution for the GS-09 grade level.

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.

You must also demonstrate the following Knowledge, Skills, and Abilities:

  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 health 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 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. **

SELECTIVE PLACEMENT FACTORS:You must possess the following in order to qualify for the position.

  1. At least 2 years of experience in positon where clinical knowledge was critical element.

  2. At least 2 years of experience working directly with electronic health records.


  1. Certified Clinical Documentation Specialist (CCDS)

  2. Registered Health Information Technician (RHIT) or Registered Health Information Administrator (RHIA)


  1. Applied knowledge of documentation impact on reimbursement.

  2. Ability to formulate program, processes and standards of practice for clinical documentation improvement program in a large and geographically diverse facility.

  3. Ability to perform and report statistical metrics and use for improvement processes.

REFERENCES: VA Handbook 5005, Part II, Appendix G35 Medical Record Technician Qualification Standards, dated September 5, 2014

PHYSICAL REQUIREMENTS: Light lifting and carrying, under 15 pounds; and repetitive computer use.

REASONABLE ACCOMODATIONS: This Agency provides reasonable accommodations to applicants with disabilities. If you need a reasonable accommodation for any part of the application and hiring process, you must notify the agency. This decision on granting reasonable accommodation will be made on a case-by-case basis.

Security Clearance


Additional Information
What To Expect Next

After we receive your complete application package (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 resume 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 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 "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 is an overview of the benefits currently offered:

Receiving Service Credit for Earning Annual (Vacation) Leave: Federal Employees earn annual leave at a rate (4, 6 or 8 hours per pay period) which is based on the number of years they have served as a Federal employee.

Other Information

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: $52,505.00 to $75,567.00 / Per Year

Series & Grade: GS-0675-09/09

Supervisory Status: No


Control Number: 453484700

Job Announcement Number: 612-17-RL-1826271-BU