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Job Details

Medical Records Tech CDI

Company name
United States Department of Veterans Affairs


West Haven, CT, United States

Employment Type

Healthcare, Administrative

Posted on
Jun 11,2019

Valid Through
Sep 24,2019

Apply for this job


This position is located in the Health Information Management Section (HIMS) of the Business Office Service line at the VA Connecticut Healthcare system. The Clinical Documentation Improvement (CDI) Specialist is responsible for the CDI program at VACT to include reviewing, abstracting, and reporting CDI and VERA-related information from patient medical records and data from these records. This position performs these coding-related functions throughout the health system

,educationRequirements:IMPORTANT: A transcript must be submitted with your application if you are basing all or part of your qualifications on 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:,employmentType:FULL_TIME,hiringOrganization:Veterans Affairs, Veterans Health Administration,jobLocation:[{@type:Place,address:{@type:PostalAddress,addressLocality:West Haven,addressRegion:CT }}],responsibilities:Duties include but are not limited to:

. Incumbent develops and conducts seminars, workshops, short courses, informational briefings, and conferences concerned with medical record documentation educational and functional training requirements to ensure program objectives are met for the VA Connecticut Healthcare System clinical and medical record staff.
. Ensures 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.
Ensures the accuracy and completeness of clinical information used for measuring and reporting physician and medical center outcomes with continuing education to all members of the patient care team on an ongoing basis.
Collaboratively works with professional clinical staff and provides support and education on documentation issues.
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.
As a technical expert in health information coding matters, provides advice and guidance on 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.
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.
Participates in clinical rounds and may, where appropriate, offer information on documentation, coding rules and reimbursement issues.
The documentation specialist is a member of the healthcare team, and as such, shall assist all clinical providers with ICD, CPT and DRG methodologies so that documentation will more accurately reflect the occurrence of the encounter.
Performs other related duties as assigned.

Work Schedule: Mon-Fri 8:00am-4:30pm
Financial Disclosure Report: Not required,qualifications:To qualify for this position, applicants must meet all requirements by the closing date of this announcement, 07/01/2019.
Basic Requirements:

\tUnited States Citizenship: Non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy.
\tEnglish Language Proficiency: MRTs must be proficient in spoken and written English as required by 38 U.S.C. 7402(d), and 7407(d).
\tOne 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.
\tEducation: 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).
\tCombination of experience and education: Equivalent combinations of experience and education are qualifying. The following educational/training substitutions are appropriate for combining education and experience:
\ta) 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.
\tb) 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.

Grade Determinations: One year of experience equivalent to the next lower grade level GS-08
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; and
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.

Assignment: For all assignments above the full performance level, the higher-level duties must consist of significant scope, complexity (difficulty), and range of variety, and be performed by the incumbent at least 25% of the time. CDISs are responsible for facilitating improved overall quality, education, and completeness and accuracy of medical record documentation as well as promoting appropriate clinical documentation through extensive interaction with physicians, other patient caregivers, HIM coding staff and other associated staff to ensure clinical documentation and services rendered to patients is complete and accurate for appropriate workload capture and resource allocations. Develop and/or update medical center policy memoranda pertaining to documentation improvement. Serve as technical expert in health record content and documentation requirements. Responsible for performing reviews of the health record documentation; developing criteria, collecting data, graphing and analyzing results, creating reports and communicating in writing and/or in person to appropriate leadership and groups. Obtain appropriate corrective action plans from responsible clinical services directors, when necessary, and recommend improvements or changes in documentation as deemed necessary. Adhere to established documentation requirements as outlined by accrediting agencies guidelines, regulations, policy and medical-legal requirements. Responsible for the development and implementation of active training/education programs (i.e. seminars, workshops, short courses, informational briefings, and conferences) for all providers to ensure the CDIS program objectives are met.

References: VA Handbook 5005, Part II, Appendix G35. This can be found in the local Human Resources Office.

Physical Requirements: The work is primarily performed while sitting though some work may require periods of standing

Company info

United States Department of Veterans Affairs
Website :

Company Profile
The Veterans Health Administration is home to the United States’ largest integrated health care system consisting of 152 medical centers, nearly 1,400 community-based outpatient clinics, community living centers, Vet Centers and Domiciliaries. Together these health care facilities and the more than 53,000 independent licensed health care practitioners who work within them provide comprehensive care to more than 8.3 million* Veterans each year.

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