Medical Records Technician (Clinical Documentation Improvement Specialist (Out/Inpatient))

<p>This position is located in the Health Information Management (HIM) section at the Kansas City VA Medical Center. MRTs (Coder) are skilled in classifying medical data from patient health records in the hospital setting, and/or physician-based settings, such as physician offices, group practices, multi-specialty clinics, and specialty centers. These coding practitioners analyze and abstract patients' health records, and assign alpha-numeric codes for each diagnosis and procedure.</p><h3>Major Duties</h3><p>The Medical Records Technician (Clinical Documentation Improvement Specialist) (CDIS) is located within the Health Information Management Section (HIMS) of the Business Operations Service (BOS) at the Kansas City VA Medical Center (KCVAMC).Incumbent provides quantitative and qualitative review and analysis of medical records and encounter forms of both inpatient and outpatient encounters to ensure all diagnoses and conditions for which care is being rendered are documented by the provider in the proper sequence, and procedures have been documented and/or evaluation and management services. Major Duties include, but are not limited to: Responsible for reviewing the overall quality and completeness of clinical documentation Applies comprehensive knowledge of medical terminology, anatomy & physiology, disease processes, treatment modalities, diagnostic tests, medications, procedures Reviews clinical documentation and provides education to clinical staff on both inpatient and outpatient episodes of care including admissions and discharges, observation, emergency department/urgent care, and clinic visits Prepare and conduct provider education on documentation processes in the health record to include the impact of documentation on coding, workload, quality measures, reimbursement, and funding Monitors ever-changing regulatory and policy requirements affecting coded information Develops and conducts seminars, workshops, short courses, informational briefings, and conferences concerned with health record documentation, educational and functional training requirements Work Schedule: Monday-Friday; 730-1600 Recruitment Incentive (Sign-on Bonus): Not Authorized Permanent Change of Station (Relocation Assistance): Not Authorized Pay: Competitive salary and regular salary increases. When setting pay, a higher step rate of the appropriate grade may be determined after consideration of higher or unique qualifications or special needs of the VA (Above Minimum Rate of the Grade). Paid Time Off: 37-50 days of annual paid time offer per year (13-26 days of annual leave, 13 days of sick leave, 11 paid Federal holidays per year) Parental Leave: After 12 months of employment, up to 12 weeks of paid parental leave in connection with the birth, adoption, or foster care placement of a child. Child Care Subsidy: After 60 days of employment, full time employees with a total family income below $144,000 may be eligible for a childcare subsidy up to 25% of total eligible childcare costs for eligible children up to the monthly maximum of $416.66. Retirement: Traditional federal pension (5 years vesting) and federal 401K with up to 5% in contributions by VA Insurance: Federal health/vision/dental/term life/long-term care (many federal insurance programs can be carried into retirement) Telework: Available Virtual: This is not a virtual position. Functional Statement #: 000000 Permanent Change of Station (PCS): Not Authorized VA Careers - Pharmacy: https://youtube.com/embed/Fn_ickNBEws VA Careers - Social Work: https://youtube.com/embed/enRhz_ua_UU VA Careers - Licensed Clinical Social Worker: https://youtube.com/embed/U_xC25QsN0w VA Careers - Microbiology/Molecular Medical Technologist: https://youtube.com/embed/eSDGhIwZKdw VA Careers - Diagnostic Radiologic Technologist: https://youtube.com/embed/I-4ku5UMvWM VA Careers - Medical Support Assistant: https://youtube.com/embed/EE9c4XkaELo VA Careers - Lead Medical Support Assistant: https://youtube.com/embed/UJO_XH5uCLs VA Careers - Licensed Practical Nurse: https://youtube.com/embed/Ae85IP1Oiz4 VA Careers - Psychologist: https://youtube.com/embed/77qHlLw9XckTotal Rewards of a Allied Health Professional</p><h3>Requirements</h3>You must be a U.S. Citizen to apply for this 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 (https://www.uscis.gov/i-9-central/form-i-9-acceptable-documents). 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.<h3>Education</h3>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: http://ope.ed.gov/accreditation/. 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: https://sites.ed.gov/international/recognition-of-foreign-qualifications/.