Veterans Affairs, Veterans Health Administration MRT (Coder) Clinical Documentation Improvement Specialist (CDIS) in Long Beach, California

Veterans Affairs, Veterans Health Administration
1 vacancy in the following location:
  • Long Beach, CA
Work Schedule is Full Time - Excepted Service Permanent

Opened Thursday 10/6/2016 (20 day(s) ago)

** Closes Thursday 10/27/2016 (1 day(s) away)

Job Overview

Vacancy Identification Number (VIN): 1820440

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.

The Department of Veterans Affairs (VA) needs employees who possess the energy, compassion, and commitment to serve those who served our Country. Whatever the job title, every position in VA will give you a chance to make a meaningful and personal contribution to the lives of truly special and deserving people - our Veterans. 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. Working for VA is one of the most emotionally satisfying and professionally rewarding ways to dedicate the best within you to your Country's service. If you are transitioning from the military or a Veteran already, we invite you to explore the benefits of continuing your career at the VA. The VA is committed to hiring Veterans. The VA is much more than just another employer. It is an honorable, open and welcoming community of those who care. Gratitude is our motivation and service is our mission. The VA has adopted Core Values and Characteristics that apply universally across the Department. The five Core Values define "who we are," our culture, and how we care for Veterans, their families and other beneficiaries. The Values are Integrity, Commitment, Advocacy, Respect and Excellence ("I CARE").

The incumbent for this position may be eligible to apply for the Education Debt Reduction Program. Please contact Human Resources at this medical center and speak with the Education Debt Reduction Program Coordinator for additional information.

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.

Recruitment / Relocation Incentive is NOT authorizeD


This position is located at Health Information Management (HIM) at VA Long Beach HealthCare System (VALBHS). The Clinical Documentation Improvement Specialist (CDIS) is a full performance level staff position. Certification at this grade is highly recommended. VA Long Beach is accredited by The Joint Commission and is an organization which is large and complex and consists of: acute hospital beds with a full range of medical and surgical services; a wide variety of outpatient clinics and services some of which are located off station; a Community Living Center (CLC), dialysis, Blind Rehabilitation; diagnostic services such as radiology and laboratory, Women’s Health, Research, etc. The health record is the primary means of ensuring continuity of care for patients by serving as the Method of documenting and communicating health information. Documentation in the health record is also used to evaluate the adequacy and appropriateness of patient care, provide clinical data for research and education, support reimbursement, medical necessity, quality care measures, meet performance metrics and public reporting for healthcare services rendered. This makes capture of complete and accurate clinical documentation at each encounter critically important.

The role of the CDIS is to identify areas for improvement in clinical documentation, perform analysis, make recommendations, implement solutions, provide education, and monitor changes to improve documentation in support of the goals of improved continuity of care for patients and of revenue enhancement. The CDIS is also responsible to perform production coding functions including accurate and timely coding of all types of inpatient and outpatient episodes using ICD, HCPCS, CPT, DSMIB, E&M; coding systems and abstracting data appropriately; collaborate and communicate with designated revenue staff to optimize third party reimbursement; collaborate with HIMS and Compliance staff to identify patterns in documentation, deficiencies in documentation, lack of specificity or medical necessity for services rendered. Collaboration will include corrective actions and education of providers and support staff. CDIS is expected to be a subject matter expert for, but not limited to: Veterans Equitable Resources Allocation (VERA) guidance, VHA Coding guidelines for current ICD, HCPCS, CPT, DSMIB, DRGs, Department of Veterans Affairs Clinical Documentation Improvement Program Guide, VHA Handbook 1907.01, Resident Supervision, Health information and Health Records, VHA Handbook 1907.03, Health Information Management Clinical Coding Program Procedures, and VHA HIM Practice Brief #11, Provider Query Process, The Joint Commission, Centers for Medicare-and Medicaid Services, Compliance and Business Integrity pertaining to coding and billing.Work Schedule:* 8:00am- 4:30pm Monday-Friday*

We are a 24/7 medical center with various tours of duty and incumbent may be required to work off tours, nights, holidays and/or weekends to meet the mission of caring for the Veterans. Functional Statement Title/#:* *Medical Records Technician-Clinical Documentation Improvement Specialist #020230

Travel Required
  • Not Required
Relocation Authorized
  • No
Job Requirements
Key Requirements
  • Must pass pre-employment examination
  • Must be proficient in written and spoken English
  • Designated and-or Random Drug Testing required
  • Background and-or Security Investigation required
  • Selective Service Registration is required for males born after 12/31/1959.

*Basic Requirements: *

Citizenship. *Citizen of the United States. (Non-citizens may be appointed when it is not possible to recruit qualified citizens in accordance with chapter 3, section A, paragraph 3g, this part.)*

Experience and Education

(1) Experience.* *One 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.


(2) * Education.* 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).


(3) Experience/Education Combination. Equivalent combinations of experience and education are qualifying. The following educational/training substitutions are appropriate for combining education and experience:

(a) 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.

(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 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.

Physical Requirements. Moderate lifting- 45 pounds and over, light carrying- under 15 pounds, reaching above shoulder, both hands required, standing 4 hours, kneeling, repeated bending, ability to distinguish basic colors, ability to distinguish shades of colors, hearing (aid premitted), near vision correctable at 13" tp 16" to Jaeger 1 to 4.

English Language Proficiency.In accordance with 38 U.S.C. 7402(d), No person shall serve in direct patient care positions unless they are proficient in basic written and spoken English. You must be proficient in basic written and spoken English in order to meet the requirements of this position.

Preferred Experience: Minimum (two years) as a coder in an acute care facility coding all specialties (inpatient, outpatient, ER, Surgery, etc..)*HIGHLY DEDSIRED CERTIFICATION:* AHIMA(RHIA, RHIT or CCS or AAPC (CPC)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.

Grade Determinations:

GS-9 MRT (Coder) Clinical Documentation Improvement Specialist (CDIS)

(a) *Experience. *One year of experience equivalent to the next lower grade level.

(b) *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.

References: VA Handbook 5005/PART II/APPENDIX G35 MEDICAL RECORD TECHNICIAN QUALIFICATION STANDARD GS-675. This can be found in the local Human Resources Office.

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.

Physical Requirements:Moderate lifting- 45 pounds and over, light carrying- under 15 pounds, reaching above shoulder, both hands required, standing 4 hours, kneeling, repeated bending, ability to distinguish basic colors, ability to distinguish shades of colors, hearing (aid premitted), near vision correctable at 13" tp 16" to Jaeger 1 to 4.

Security Clearance

Not Applicable

Additional Information
What To Expect Next

After we receive application packages (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 résumé 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 receive a notification letter via the U.S. Postal Service. Referred 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 on “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: $54,664.00 to $71,058.00 / Per Year

Series & Grade: GS-0675-09/09

Supervisory Status: No

Who May Apply: United States Citizens

Control Number: 452782100

Job Announcement Number: VR 1820440 H 16-144 BU (DN)