This position is located in the Health Information Management (HIM) Section, under the Business Office, at the VA Medical Center, Atlanta, Ga. Medical Records Technicians (Coders) are skilled in classifying medical data from patient health records. These coding practitioners analyze patients' health records and assign alpha-numeric codes for each diagnosis and procedure.
Major Duties Include but are not limited to: Reviewing the overall quality and completeness of clinical documentation. Applying comprehensive knowledge of medical terminology, anatomy & physiology, disease processes, treatment modalities, diagnostic tests, medications, procedures as well as the principles and practices of health services and the organizational structure to ensure proper code selection.
Reviewing clinical documentation and providing education to clinical staff on inpatient and outpatient episodes of care. Preparing and conducting provider education on documentation processes in the health record to include the impact of documentation on coding, workload, quality measures, reimbursement, and funding.
Providing education to providers on the need for accurate and complete documentation in the health record, ensuring documentation supports the codes selected to the highest degree of specificity. Adhering to accepted coding practices, guidelines, and conventions to ensure ethical, accurate, and complete coding. Ensuring provider documentation is complete and supports the diagnoses and procedures coded.
Serves as the liaison between health information management and clinical staff and is responsible for facilitating the improved overall quality, education, completeness and accuracy of health record documentation through extensive interaction with clinical coding, and other associated staff to ensure clinical documentation supports services rendered to patients, appropriate workload is captured, and resources are properly allocated.
Reviews documentation and facilitate modifications to the health record to ensure accurate severity of illness, risk of mortality, complexity of care, and utilization of resources. Responsible for reviewing the overall quality and completeness of clinical documentation.
Inpatient CDI focuses on the concurrent review of patient records with an emphasis on improving documentation while the patient is still in-house while outpatient CDI focuses on improving clinical staff documentation of outpatient encounters through retrospective, ideally prior to coding and billing, review of outpatient encounters and extensive provider education.
Queries clinical staff to clarify ambiguous, conflicting, or incomplete documentation and reviews the appropriateness of and responses to queries through review of query reports. Obtains appropriate corrective action plans from responsible clinical service directors and recommend improvements or changes in documentation practices, when applicable.
Reviews VERA input on missed opportunities in provider documentation identified by the VERA coordinator and coordinate provider documentation education with the VERA coordinator.
Ensures documentation supports codes based on guidelines specific to certain diagnoses, procedures, and other criteria used to classify patients under the Veterans Equitable Resource Allocation (VERA) program that categorizes all VA patients into specific classes representing their clinical conditions and resource needs.
Incumbent develops and conducts seminars, workshops, short courses, informational briefings, and conferences concerned with health record documentation, educational and functional training requirements to ensure program objectives are met for clinical and Health Information Management (HIM) staff. Work Schedule: Full-time, Monday-Friday, 8:00am-4:30pm. (Subject to change based on agency need.) Telework: 5 Days per pay period Virtual: This is not a virtual position.
Functional Statement #: 60956F Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized
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/.
This position is with Veterans Health Administration, Department of Veterans Affairs.
The posted pay range is $65271 – $84857/yr.
This position is eligible for telework.
This position requires a Other security clearance.
Applications close on 2026-10-30.
This position is open under the 'Fed Internal Search' hiring path.
Source: USAJOBS.gov — U.S. Federal Government · Retrieved 2026-10-20 · Not affiliated with or endorsed by OPM or USAJOBS.gov
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