This position is located in the Health Information Management section at the Fayetteville NC VA Coastal Health Care System. 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.
Duties include but not limited to: Must be able to perform all duties of a Medical Records Technician (Coder-Inpatient and Outpatient).
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. Identifies opportunities for documentation improvement by ensuring that diagnoses and procedures are documented to the highest level of specificity, accurately address all acute and chronic conditions, and reflect the true health status of patients.
Develops and/or updates medical center policy pertaining to clinical documentation improvement. Serves as a technical expert in health record content and documentation requirements. 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. Reviews health record documentation, develop criteria, collect data, graph and analyze results, create reports, and communicate orally and/or in writing to appropriate groups and leadership.
Obtains appropriate corrective action plans from responsible clinical service directors and recommend improvements or changes in documentation practices, when applicable.
Adheres to established documentation requirements as outlined by accrediting agencies guidelines, regulations, policies, and medical-legal requirements and monitors trends in the industry and/or changes in regulations that could, or should, impact coding and documentation practices and identify who may require education.
Maintains the responsibility for the development and implementation of active training/education programs (i.e., seminars, workshops, short courses, informational briefings, and conferences) for all clinical staff to ensure the CDIS program objectives are met. They provide training in small or large groups, educating clinical staff about current documentation standards and improvement techniques, including accurate and ethical documentation practices.
Applies 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 toensure proper code selection.
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. 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.
Assists facility staff with documentation requirements to completely and accurately reflect the patient care provided; provides technical support in the areas of regulations and policy, coding requirements, resident supervision, reimbursement, workload, accepted nomenclature, and proper sequencing. OTHER DUTIES AS ASSIGNED Work Schedule: Monday-Friday, 8:00 a.m. to 4:30 p.m.
Recruitment/Relocation Incentives (Sign-on Bonus): May be authorized for new to federal service applicants ONLY; $6,381.50 for a 2-year service agreement Telework: Available Virtual: This is not a virtual position. Functional Statement #: 0000 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/.
MARIA.ESPINOSASOLIS@va.gov · 909-850-1812
This position is with Veterans Health Administration, Department of Veterans Affairs.
The posted pay range is $64453 – $83794/yr.
This position is eligible for telework.
Applications close on 2026-11-04.
This position is open under the 'Public' hiring path.
Source: USAJOBS.gov — U.S. Federal Government · Retrieved 2026-10-28 · Not affiliated with or endorsed by OPM or USAJOBS.gov
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