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

Medical Records Technician (Clinical Documention Improvement Specialist- Outpient/Inpient) Department of Veterans Affairs Veterans Health Administrion Atlanta VA Health Care System/Health Informion Management /Health Administrion Services Summary This position is loced in the Health Informion Management (HIM) Section, under the Business Office, the VA Medical Center, Atlanta, Ga. Medical Records Technicians (Coders) are skilled in classifying medical da from pient health records. These coding practitioners analyze pients' health records and assign alpha-numeric codes for each diagnosis and procedure. Learn more about this agency Summary This position is loced in the Health Informion Management (HIM) Section, under the Business Office, the VA Medical Center, Atlanta, Ga. Medical Records Technicians (Coders) are skilled in classifying medical da from pient health records. These coding practitioners analyze pients' health records and assign alpha-numeric codes for each diagnosis and procedure. Learn more about this agency Overview Help Accepting applicions Open & closing des 05/01/2026 to 05/08/2026 This job will close when we have received 50 applicions which may be sooner than the closing de. Learn more Salary $65,271 - $84,857 per year Pay scale & grade GS 9 Locion 1 vacancy in the following locion: Atlanta, GA Remote job No Telework eligible No Travel Required Not required Relocion expenses reimbursed No Appointment type Permanent Work schedule Full-time Service Excepted Promotion potential None Job family (Series) 0675 Medical Records Technician Supervisory stus No Security clearance Not Required Drug test No Position sensitivity and risk Non-sensitive (NS)/Low Risk Trust determinion process Credentialing Suitability/Fitness Financial disclosure No Bargaining unit stus Yes Announcement number

CBTB-12947413-26-TJ

Control number 867290700 This job is open to Help 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, permanent Veterans Health Administrion employees only. Videos Duties Help Major Duties Include but are not limited to: Reviewing the overall quality and completeness of clinical documention. Applying comprehensive knowledge of medical terminology, anomy & physiology, disease processes, trement modalities, diagnostic tests, medicions, procedures as well as the principles and practices of health services and the organizional structure to ensure proper code selection. Reviewing clinical documention and providing educion to clinical staff on inpient and outpient episodes of care. Preparing and conducting provider educion on documention processes in the health record to include the impact of documention on coding, workload, quality measures, reimbursement, and funding. Providing educion to providers on the need for accure and complete documention in the health record, ensuring documention supports the codes selected to the highest degree of specificity. Adhering to accepted coding practices, guidelines, and conventions to ensure ethical, accure, and complete coding. Ensuring provider documention is complete and supports the diagnoses and procedures coded.

Work Schedule :

Full-time, Monday-Friday, 8:00am-4:30pm. (Subject to change based on agency need.)

Telework :

Not Available Virtual:

This is not a virtual position. Functional Stement # : 60956

F Relocion/Recruitment Incentives :

Not Authorized Permanent Change of Stion (PCS): Not Authorized Requirements Help Conditions of employment You must be a U.S. Citizen to apply for this job. All applicants tentively selected for VA employment in a testing designed position are subject to urinalysis to screen for illegal drug use prior to appointment. Applicants who refuse to be tested denied employment with VA. Selective Service Registrion is required for males born after 12/31/1959. Must be proficient in written and spoken English. 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. Must pass pre-employment physical examinion. Participion in the seasonal influenza vaccinion program is a requirement for all Department of Veterans Affairs Health Care Personnel (HCP). Complete all applicion requirements detailed in the "Required Documents" section of this announcement. As a condition of employment for accepting this position, you required to serve a 1 or 2-year trial period during which we will evalue 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 organizional 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 termined unless you receive certificion, in writing, th your continued employment advances the public interest. 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 and Educion :

(1) 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, (2) 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, (3) 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, (4) 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: (a) 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. (b) 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. (2) Mastery Level Certificion through AHIMA or AAPC. (3) Clinical Documention Improvement Certificion through AHIMA or

ACDIS. NOTE

Mastery level certificion is required for all positions above the journey level; however, for clinical documention improvement specialist assignments, a clinical documention improvement certificion may be substituted for a mastery level certificion. 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).

Grandfhering Provision:

All persons employed in VHA as a MRT (Coder) on the effective de of this qualificion standard are considered to have met all qualificion requirements for the title, series, and grade held, including positive educion and certificion th are part of the basic requirements of the occupion. For employees who do not meet all the basic requirements in this standard, but who met the qualificions applicable to the position the time they were appointed to it. Such employees may be reassigned, promoted up to and including the journey level (GS-08), or changed to lower grade within the occupion, but will not be promoted beyond the journey level or placed in supervisory or managerial positions.

Grade Determinions :

GS-9:

Experience:

One year of creditable experience equivalent to the journey grade level of a MRT (Coder-Outpient and 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:

i. Knowledge of coding and documention concepts, guidelines, and clinical 25 terminology. ii. Knowledge of anomy and physiology, phophysiology, and pharmacology 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. iii. Ability to collect and analyze da and present results in various forms, which may include presenting reports to various organizional levels. iv. Ability to establish and maintain strong verbal and written communicion with providers. v. Knowledge of regulions th define healthcare documention requirements, including The Joint Commission, CMS, and VA guidelines. vi. Extensive knowledge of coding rules and regulions, to include current clinical classificion systems such as ICDCM and PCS, CPT, and HCPCS. They must also possess knowledge of complicion or comorbidity/major complicion or comorbidity (CC/MCC), MS-DRG structure, and POA indicors. vii. Knowledge of severity of illness, risk of mortality, complexity of care for inpients, and CPT Evaluion and Management (E/M) criteria to ensure the correct selection of E/M codes th mch pient type, setting of service, and level of E/M service provided for outpients. viii. 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.

Reference:

VA Handbook 5005/122, Part II Appendix G57. For more informion on this qualificion standard, please https://www.va.gov/ohrm/QualificionStandards/ . The full performance level of this vacancy is GS-09.

Physical Requirements:

This work is primarily sedentary with long periods of sitting a desk, working with computers daily

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: http://ope.ed.gov/accredition/ . 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, : https://sites.ed.gov/internional/recognition-of-foreign-qualificions/ . Additional informion 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, Human Resources and Administrion/Operions, Security, and Preparedness (HRA/OSP) The Fair Chance Act . Expand Hide additional informion Candides should be committed to improving the efficiency of the Federal government, passione about the ideals of our American republic, and committed to upholding the rule of law and the United Stes Constitution. Benefits Help 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 Learn more about federal benefits . Review our benefits 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 evalued You evalued for this job based on how well you meet the qualificions above.

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 VA for Vets 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 Help 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 Learn more about federal benefits . Review our benefits 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 Required Documents Help To apply for this position, you must provide a complete Applicion Package which includes: Professional Certificion Resume SF-50/ Notificion of Personnel Action Special Note for

Applicions:

To complete your applicion, please use the following link https://vacareers.va.gov/wp-content/uploads/sites/5/Resume.docx to download the standard Clinical Resume Document. This one-page document does not need to be modified and must be uploaded into the two-page restricted 'Resume' document upload field. Your full resume/CV may be uploaded without page limition into the 'Other' document upload field. 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 DD-214/ Stement of Service Disability Letter (Schedule A) Disability Letter (VA) License Other (1) Performance Appraisal Professional Certificion Resume Separion Notice (RIF) SF-15 SF-50/ Notificion of Personnel Action Transcript 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 schools accredited by accrediting institutions recognized by the U.S. Department of Educion . 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 Help 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 05/08/2026 to receive considerion. To preview the questionnaire click https://apply.usastaffing.gov/ViewQuestionnaire/12947413 . 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 Tamika Johnson Phone 334-272-4670 X34015 tamika.johnson1@va.gov Address Atlanta VA Medical Center 1670 Clairmont Road Decur, GA 30033 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 USAJobs Help Center .

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. Criminal history inquiries Equal Employment Opportunity (EEO) Policy Financial suitability New employee probionary period Privacy Act Reasonable accommodion policy Selective Service Signure and false stements Social security number request Required Documents Help To apply for this position, you must provide a complete Applicion Package which includes: Professional Certificion Resume SF-50/ Notificion of Personnel Action Special Note for

Applicions:

To complete your applicion, please use the following link https://vacareers.va.gov/wp-content/uploads/sites/5/Resume.docx to download the standard Clinical Resume Document. This one-page document does not need to be modified and must be uploaded into the two-page restricted 'Resume' document upload field. Your full resume/CV may be uploaded without page limition into the 'Other' document upload field. 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 DD-214/ Stement of Service Disability Letter (Schedule A) Disability Letter (VA) License Other (1) Performance Appraisal Professional Certificion Resume Separion Notice (RIF) SF-15 SF-50/ Notificion of Personnel Action Transcript 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 schools accredited by accrediting institutions recognized by the U.S. Department of Educion . 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 Help 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 05/08/2026 to receive considerion. To preview the questionnaire click https://apply.usastaffing.gov/ViewQuestionnaire/12947413 . 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. Expand Hide how to apply Agency contact informion Tamika Johnson Phone 334-272-4670 X34015 tamika.johnson1@va.gov Address Atlanta VA Medical Center 1670 Clairmont Road Decur, GA 30033 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 USAJobs Help Center .

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. Expand Hide next steps Fair and transparent The Federal hiring process is set up to be fair and transparent. Please read the following guidance. Criminal history inquiries Equal Employment Opportunity (EEO) Policy Financial suitability New employee probionary period Privacy Act Reasonable accommodion policy Selective Service Signure and false stements Social security number request Overview Help Accepting applicions Open & closing des 05/01/2026 to 05/08/2026 This job will close when we have received 50 applicions which may be sooner than the closing de. Salary $65,271 - $84,857 per year Pay scale & grade GS 9 Locion 1 vacancy in the following locion: Atlanta, GA Remote job No Telework eligible No 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

CBTB-12947413-26-TJ

Control number 867290700