Medical Records Technician (CDIS-Inpatient) Position Available In St. Louis City, Missouri

Medical Records Technician (CDIS-Inpient) Department of Veterans Affairs Veterans Health Administrion VA St. Louis (John Cochran Division) Summary This position is in the Health Informion Management (HIM) section the VA St. Louis Health Care System (VASTLHCS) in St. Louis, Missouri. MRTs (Coder) are skilled in classifying medical da from pient health records in the hospital setting, and/or physician-based settings, such as physician offices, group practices, multi-specialty clinics, and specialty centers. Coding practitioners analyze/abstract pient health records and assign alpha-numeric codes for each diagnosis/procedure. Overview Accepting applicions Open & closing des 06/20/2025 to 06/30/2025 Salary $62,662 – $81,458 per year Pay scale & grade GS 9 Locion 1 vacancy in the following locion: Saint Louis, MO Remote job No Telework eligible Yes—as determined by the agency policy (Ad-Hoc). Travel Required Not required Relocion expenses reimbursed No Appointment type Permanent Work schedule Full-time Service Excepted Promotion potential None Job family (Series) Supervisory stus No Security clearance Drug test No Position sensitivity and risk Trust determinion process Financial disclosure Bargaining unit stus Announcement number

CBSS-12747572-25-CB

Control number 839188200 This job is open to Federal employees – Excepted service Current federal employees whose agencies have their own hiring rules, pay scales and evaluion criteria. Internal to an agency Current federal employees of the hiring agency th posted the job announcement. Clarificion from the agency This announcement is open to current federal employees. Videos Duties Medical Records Technician (Clinical Documention Improvement Specialist (CDIS-Inpient)) must possess expertise in the Internional Classificion of Diseases (ICD), Current Procedural Terminology (CPT), and the Healthcare Common Procedure Coding System (HCPCS). MRT (Coder) may also provide educion reled to coding and documention. Inpient CDI focuses on the concurrent review of pient records with an emphasis on improving documention while the pient is still in-house. Applies comprehensive knowledge of medical terminology, anomy & physiology, disease processes, trement modalities, diagnostic tests, medicions, and procedures as well as the principles and practices of health services and the organizional structure to ensure proper code selection. Major duties include, but are not limited to the following: Must be able to perform all duties of an MRT (Coder-Inpient) Responsible for reviewing the overall quality and completeness of clinical documention Serve as the liaison between health informion management and clinical staff Review documention and facilite modificions to the health record Identify opportunities for documention improvement Ensure th diagnoses and procedures are documented to the highest level of specificity Develop and/or upde medical center policy about clinical documention Query clinical staff to clarify ambiguous, conflicting, or incomplete documention Perform reviews of the health record documention Adhere to established documention requirements Develop and implement training/educion programs for clinical staff Reviews VERA input and collabore with VERA coordinor Participes in clinical rounds and may offer informion on documention, coding rules, and reimbursement issues

Work Schedule :

Monday – Friday; 8:00am – 4:30pm

CST Telework :

Available Virtual:

This is not a virtual position. Functional Stement # : 000000

Relocion/Recruitment Incentives :

Not Authorized Permanent Change of Stion (PCS): Not Authorized Requirements Conditions of Employment You must be a U.S. Citizen to apply for this job. Selective Service Registrion is required for males born after 12/31/1959. Must be proficient in written and spoken English. You may be required to serve a probionary period. Subject to background/security investigion. Selected applicants required to complete an online onboarding process. Acceptable form(s) of identificion 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 ste-issued dentificion cards th are not REAL ID compliant cannot be utilized as an acceptable form of identificion for employment. Participion in the seasonal influenza vaccinion program is a requirement for all Department of Veterans Affairs Health Care Personnel (HCP). Qualificions Applicants pending the completion of educional or certificion/licensure requirements may be referred and tentively selected but may not be hired until all requirements are met.

Basic Requirements :

United Stes Citizenship:

Non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy.

Experience or Educion:

Experience . One year of creditable experience th indices knowledge of medical terminology, anomy, physiology, phophysiology, medical coding, and the structure and form of a health records. OR , Educion . An associe’s degree from an accredited college or university recognized by the U.S. Department of Educion with a major field of study in health informion technology/health informion management, or a reled degree with a minimum of 12 semester hours in health informion technology/health informion management (e.g., courses in medical terminology, anomy and physiology, medical coding, and introduction to health records); OR , Completion of an AHIMA approved coding program, or other intense coding training program of approximely one year or more th included courses in anomy and physiology, medical terminology, basic ICD diagnostic/procedural, and basic CPT coding. The training program must have led to eligibility for coding certificion/certificion examinion, and the sponsoring academic institution must have been accredited by a nional U.S. Department of Educion accreditor, or comparable internional accrediting authority the time the program was completed; OR ; Experience/Educion Combinion. Equivalent combinions of creditable experience and educion are qualifying for meeting the basic requirements. The following educional/training substitutions are approprie for combining educion and creditable experience: Six months of creditable experience th indices knowledge of medical 4 terminology, general understanding of medical coding and the health record, and one year above high school, with a minimum of 6 semester hours of health informion technology courses. 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 anomy, physiology, and health record techniques and procedures. Also, requires six additional months of creditable experience th is paid or non-paid employment equivalent to a MRT (Coder). Certificion. Persons hired or reassigned to MRT (Coder) positions in the GS-0675 series in VHA must have either (1), (2), or (3) below: (1) Apprentice/Associe Level Certificion through AHIMA or AAPC. This is considered an entry level coding certificion and is limited to certificion obtained through the American Health Informion Management Associion (AHIMA), or the American Academy of Professional Coders (AAPC). To be acceptable for qualificions, the specific certificion must represent a comprehensive competency in coding across a wide range of services. Stand-alone specialty certificions do not meet the definition of apprentice/associe level certificion and are not acceptable for qualificions. Certificion titles may change and certificions th meet the definition of apprentice/associe level certificion may be added/removed by the above certifying bodies. However, current apprentice/associe level certificions include: Certified Coding Associe (CCA), Certified Professional Coder-Apprentice (CPC-A) and Certified Outpient Coding Apprentice (COC-A). (2) Mastery Level Certificion through AHIMA or AAPC. This is considered a higher-level health informion management or coding certificion and is limited to certificion obtained through AHIMA or AAPC. To be acceptable for qualificions, the specific certificion must represent a comprehensive competency in the occupion. Stand-alone specialty certificions do not meet the definition of mastery level certificion and are not acceptable for qualificions. Certificion titles may change and certificions th meet the definition of mastery level certificion may be added/removed by the above certifying bodies. However, current mastery level certificions include: Certified Coding Specialist (CCS), Certified Coding Specialist – Physician-based (CCS-P), Registered Health Informion Technician (RHIT), Registered Health Informion Administror (RHIA), Certified Professional Coder (CPC), Certified Outpient Coder (COC), Certified Inpient Coder (CIC). (3) Clinical Documention Improvement Certificion through AHIMA or ACDIS. This is limited to certificion obtained through AHIMA or the Associion of Clinical Documention Improvement 3 Specialists (ACDIS). To be acceptable for qualificions, the specific certificion must certify mastery in clinical documention. Certificion titles may change, and certificions th meet the definition of clinical documention improvement certificion may be added/removed by the above certifying bodies. However, current Clinical Documention Improvement Certificions include: Clinical Documention Improvement Practitioner (CDIP) and Certified Clinical Documention Specialist. May qualify based on being covered by the Grandfhering Provision as described in the VA Qualificion Standard for this occupion (only applicable to current VHA employees who are in this occupion and meet the criteria).

Educion Qualificions Continued Grade Determinions:

Medical Records Technician (Clinical Documention Improvement Specialist (CDIS – Inpient)), GS-9 Experience . One year of creditable experience equivalent to the journey grade level of a MRT (Coder-inpient); OR , An associe’s degree or higher, and three years of experience in clinical documention improvement (candides must also have successfully completed coursework in medical terminology, anomy and physiology, medical coding, and introduction to health records); OR , Mastery level certificion through AHIMA or AAPC, and two years of experience in clinical documention improvement; OR , Clinical experience such as RN, M.D., or DO, and one year of experience in clinical documention improvement. Certificion . Employees this level must have either a mastery level certificion or a clinical documention improvement certificion . Demonstred Knowledge, Skills, and Abilities. In addition to the experience above, the candide must demonstre all of the following

KSAs:

Knowledge of coding and documention concepts, guidelines, and clinical terminology. Knowledge of anomy and physiology, phophysiology, and pharmacology in order to interpret and analyze all informion in a pient’s health record, including laborory and other test results, to identify opportunities for more precise and/or complete documention in the health record. Ability to collect and analyze da and present results in various forms, which may include presenting reports to various organizional levels. Ability to establish and maintain strong verbal and written communicion with providers. Knowledge of regulions th define healthcare documention requirements, including The Joint Commission, CMS, and VA guidelines. Extensive knowledge of coding rules and regulions, to include current clinical classificion systems such as ICD CM and PCS. They must also possess a knowledge of complicion or comorbidity/major complicion or comorbidity (CC/MCC), MS-DRG structure, and POA indicors. Knowledge of severity of illness, risk of mortality, and complexity of care. Knowledge of training methods and teaching skills sufficient to conduct continuing educion for staff development. The training sessions may be technical in nure or may focus on teaching techniques for the improvement of clinical documention issues.

Preferred Experience:

+3 years of experience coding

Reference:

For more informion on this qualificion standard, please . This position is above the full performance level. The actual grade which an applicant may be selected for this vacancy is GS-09.

Physical Requirements:

Use of Computerized Systems. Educion

IMPORTANT

A transcript must be submitted with your applicion if you are basing all or part of your qualificions on educion.

Note:

Only educion or degrees recognized by the U.S. Department of Educion from accredited colleges, universities, schools, or institutions may be used to qualify for Federal employment. You can verify your educion here: . If you are using foreign educion to meet qualificion requirements, you must send a Certifice of Foreign Equivalency with your transcript in order to receive credit for th educion. For further informion, : . Additional informion Receiving Service Credit or Earning Annual (Vacion)

Leave:

Federal Employees earn annual leave a re (4, 6 or 8 hours per pay period) which is based on the number of years they have served as a Federal employee. Selected applicants may qualify for credit toward annual leave accrual, based on prior work experience or military service experience. This credited service can be used in determining the re which they earn annual leave. Such credit must be requested and approved prior to the appointment de and is not guaranteed. During the applicion 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 applicion for this announcement, nor does it guarantee further considerion 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 stus. VA encourages persons with disabilities to apply. The health-reled 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 alterne method to submit documents, please reach out to the Agency Contact listed in this Job Opportunity Announcement. Under the Fair Chance to Compete Act, the Department of Veterans Affairs prohibits requesting an applicant’s criminal history prior to accepting a tentive job offer. For more informion about the Act and the complaint process, . Benefits A career with the U.S. government provides employees with a comprehensive benefits package. As a federal employee, you and your family will have access to a range of benefits th are designed to make your federal career very rewarding. Opens in a new window . Eligibility for benefits depends on the type of position you hold and whether your position is full-time, part-time or intermittent. Contact the hiring agency for more informion on the specific benefits offered. How You Will Be Evalued You evalued for this job based on how well you meet the qualificions above.

Area of Considerion:

Eligible applicions reviewed and referred in the following order: 1. Current permanent VA employees of the facility. 2. All other VA employees. 3. Current permanent Federal employees of other agencies. 4. All other applicants.

Note:

Veterans’ Preference is not applicable to VA employees or employees of other Federal agencies.

IN DESCRIBING YOUR EXPERIENCE, PLEASE BE CLEAR AND SPECIFIC. WE MAY NOT MAKE ASSUMPTIONS REGARDING YOUR EXPERIENCE.

Your applicion, resume, C.V., and/or supporting documention verified. Please follow all instructions carefully. Errors or omissions may affect considerion for employment. Experience refers to paid and unpaid experience, including volunteer work done through Nional Service programs (e.g., Peace Corps, AmeriCorps) and other organizions (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 th transles 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 informion provided by a candide (e.g., on resume or during interview or hiring process); gain additional knowledge regarding a candide’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 th have faced financial hardships or periods of unemployment.

Veterans and Transitioning Service Members :

Please the site for career-search tools for Veterans seeking employment VA, career development services for our existing Veterans, and coaching and reintegrion support for military service members. Benefits A career with the U.S. government provides employees with a comprehensive benefits package. As a federal employee, you and your family will have access to a range of benefits th are designed to make your federal career very rewarding. Opens in a new window . Eligibility for benefits depends on the type of position you hold and whether your position is full-time, part-time or intermittent. Contact the hiring agency for more informion on the specific benefits offered. Required Documents As a new or existing federal employee, you and your family may have access to a range of benefits. Your benefits depend on the type of position you have – whether you’re a permanent, part-time, temporary or an intermittent employee. You may be eligible for the following benefits, however, check with your agency to make sure you’re eligible under their policies. To apply for this position, you must provide a complete Applicion Package which includes: Resume SF-50/ Notificion of Personnel Action The following documents are accepted, and may be required if applicable to your eligibility and/or qualificions for this position. Please ensure you have included all documents required for your applicion, such as a copy of your transcript (if using educion to qualify), SF-50’s (current/former Federal employees), etc. Cover Letter Disability Letter (VA) Other (1) Professional Certificion Resume SF-50/

Notificion 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 des 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 documention reled to your active duty service which reflects the des of service, character of service (honorable, general, etc.), and des of impending separion. Additionally, disabled veterans and others eligible for 10-point preference (such as widows or mothers of eligible Veterans) must also submit an SF-15 “Applicion for 10 Point Veteran Preference” with required proof as sted on the form. Documention is required to award preference. For more informion on Veterans’ Preference, please . Veterans’ preference does not apply for internal or other current permanent Federal agency employees. If you are relying on your educion to meet qualificion requirements: Educion must be accredited by an accrediting institution recognized by the U.S. Department of Educion in order for it to be credited towards qualificions. Therefore, provide only the tendance and/or degrees from . Failure to provide all of the required informion as sted in this vacancy announcement may result in an ineligible ring or may affect the overall ring. How to Apply All applicants are encouraged to apply online. To apply for this position, you must complete the full questionnaire and submit the documention specified in the Required Documents section below. The complete applicion package must be submitted by 11:59 PM (ET) on 06/30/2025 to receive considerion. To preview the questionnaire click . To begin, click Apply Online to cree a USAJOBS account or log in to your existing account. Follow the prompts to select your

USA JOBS

resume and/or other supporting documents and complete the occupional questionnaire. Click Submit My Answers to submit your applicion package.

NOTE:

It is your responsibility to ensure your responses and approprie documention is submitted prior to the closing de. Agency contact informion Celena Bruce Phone Address VA St Louis Health Care System 1 Jefferson Barracks Drive St. Louis, MO 63125 US Next steps Once your online applicion is submitted you will receive a confirmion notificion by email. After we receive applicion packages (including all required documents) and the vacancy announcement closes, we will review applicions to ensure qualificion and eligibility requirements are met. After the review is complete, a referral certifice(s) is issued and applicants notified of their stus by email. Referred applicants notified as such and may be contacted directly by the hiring office for an interview. All referred applicants receive a final notificion once a selection decision has been made. You may check the stus of your applicion any time by logging into your USA Jobs account and clicking on Applicions. Informion regarding your applicion stus can be found in the .

NOTE:

Participion 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 th all HCP to receive annual seasonal influenza vaccinion or obtain an exemption for medical or religious reasons. Wearing a face mask is required when an exemption to the influenza vaccinion has been granted. HCP in violion 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 locions or who come into contact with VA pients or other HCP as part of their duties. VHA locions include, but are not limited to, VA hospitals and associed clinics, community living centers (CLCs), community-based outpient clinics (CBOCs), domiciliary units, Vet centers and VA-leased medical facilities. HCP include all VA licensed and unlicensed, clinical and administrive, remote and onsite, paid and without compension, 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 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 pients outside VA medical facilities. Fair and Transparent The Federal hiring process is set up to be fair and transparent. Please read the following guidance. Required Documents To apply for this position, you must provide a complete Applicion Package which includes: Resume SF-50/ Notificion of Personnel Action The following documents are accepted, and may be required if applicable to your eligibility and/or qualificions for this position. Please ensure you have included all documents required for your applicion, such as a copy of your transcript (if using educion to qualify), SF-50’s (current/former Federal employees), etc. Cover Letter Disability Letter (VA) Other (1) Professional Certificion Resume SF-50/

Notificion 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 des 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 documention reled to your active duty service which reflects the des of service, character of service (honorable, general, etc.), and des of impending separion. Additionally, disabled veterans and others eligible for 10-point preference (such as widows or mothers of eligible Veterans) must also submit an SF-15 “Applicion for 10 Point Veteran Preference” with required proof as sted on the form. Documention is required to award preference. For more informion on Veterans’ Preference, please . Veterans’ preference does not apply for internal or other current permanent Federal agency employees. If you are relying on your educion to meet qualificion requirements: Educion must be accredited by an accrediting institution recognized by the U.S. Department of Educion in order for it to be credited towards qualificions. Therefore, provide only the tendance and/or degrees from . Failure to provide all of the required informion as sted in this vacancy announcement may result in an ineligible ring or may affect the overall ring. How to Apply All applicants are encouraged to apply online. To apply for this position, you must complete the full questionnaire and submit the documention specified in the Required Documents section below. The complete applicion package must be submitted by 11:59 PM (ET) on 06/30/2025 to receive considerion. To preview the questionnaire click . To begin, click Apply Online to cree a USAJOBS account or log in to your existing account. Follow the prompts to select your

USA JOBS

resume and/or other supporting documents and complete the occupional questionnaire. Click Submit My Answers to submit your applicion package.

NOTE:

It is your responsibility to ensure your responses and approprie documention is submitted prior to the closing de. Agency contact informion Celena Bruce Phone Address VA St Louis Health Care System 1 Jefferson Barracks Drive St. Louis, MO 63125 US Next steps Once your online applicion is submitted you will receive a confirmion notificion by email. After we receive applicion packages (including all required documents) and the vacancy announcement closes, we will review applicions to ensure qualificion and eligibility requirements are met. After the review is complete, a referral certifice(s) is issued and applicants notified of their stus by email. Referred applicants notified as such and may be contacted directly by the hiring office for an interview. All referred applicants receive a final notificion once a selection decision has been made. You may check the stus of your applicion any time by logging into your USA Jobs account and clicking on Applicions. Informion regarding your applicion stus can be found in the .

NOTE:

Participion 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 th all HCP to receive annual seasonal influenza vaccinion or obtain an exemption for medical or religious reasons. Wearing a face mask is required when an exemption to the influenza vaccinion has been granted. HCP in violion 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 locions or who come into contact with VA pients or other HCP as part of their duties. VHA locions include, but are not limited to, VA hospitals and associed clinics, community living centers (CLCs), community-based outpient clinics (CBOCs), domiciliary units, Vet centers and VA-leased medical facilities. HCP include all VA licensed and unlicensed, clinical and administrive, remote and onsite, paid and without compension, 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 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 pients outside VA medical facilities. Fair & Transparent The Federal hiring process is set up to be fair and transparent. Please read the following guidance. Overview Accepting applicions Open & closing des 06/20/2025 to 06/30/2025 Salary $62,662 – $81,458 per year Pay scale & grade GS 9 Locion 1 vacancy in the following locion: Saint Louis, MO Remote job No Telework eligible Yes—as determined by the agency policy (Ad-Hoc). Travel Required Not required Relocion expenses reimbursed No Appointment type Permanent Work schedule Full-time Service Excepted Promotion potential None Job family (Series) Supervisory stus No Security clearance Drug test No Position sensitivity and risk Trust determinion process Financial disclosure Bargaining unit stus Announcement number

CBSS-12747572-25-CB

Control number 839188200 ., .