The Medical Records Technician - Clinical Documentation Improvement Specialist - Outpatient and Inpatient is located in the Health Information Management (HIM) section at the Miami VA Healthcare System. They analyze and abstract patients' health records and assign alpha-numeric codes for each diagnosis and procedure.
They must possess expertise in International Classification Diseases (ICD), Current Procedural Terminology (CPT), and the Healthcare Common Procedure Coding System (HCPCS).
Recruitment Incentive (Sign-on Bonus):Not Authorized Permanent Change of Station (Relocation Assistance): Not Authorized Pay: Competitive salary and regular salary increases. Paid Time Off: 37-50 days of annual paid time offer per year (13-26 days of annual leave, 13 days of sick leave, 11 paid Federal holidays per year).Selected applicants may qualify for credit toward annual leave accrual, based on prior work experience or military service experience.
Parental Leave: After 12 months of employment, up to 12 weeks of paid parental leave in connection with the birth, adoption, or foster care placement of a child. Child Care Subsidy: After 60 days of employment, full time employees with a total family income below $144,000 may be eligible for a childcare subsidy up to 25% of total eligible childcare costs for eligible children up to the monthly maximum of $416.66.
Retirement: Traditional federal pension (5 years vesting) and federal 401K with up to 5% in contributions by VA Insurance: Federal health/vision/dental/term life/long-term care (many federal insurance programs can be carried into retirement) Remote:100% remote, pending exemption to RTO EO Telework: Maybe Authorized Virtual: This is not a virtual position.
Functional Statement #: 30326F Permanent Change of Station (PCS): Not Authorized Recruitment Incentive (Sign-on Bonus): Not Authorized Permanent Change of Station (Relocation Assistance): Not Authorized As a Medical Records Technician (Clinical Documentation Improvement Specialist - Outpatient and Inpatient, you will be responsible: Assisting 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.
Ensures provider documentation is complete and supports the diagnoses and procedures coded. Directly consults with the professional staff for clarification of conflicting or ambiguous clinical data. Reports incorrect documentation or codes in the electronic patient health record. Collaboratively working with the professional clinical staff and provides support and education on documentation issues.
Assists in the development of guidelines for data compatibility, consistency, and monitoring for compliance to improve the quality for clinical, financial, and administrative data to ensure that all information is fully documented and supported. Such efforts are conducted to ensure the accuracy of billing denials and prevention against fraud and abuse and to optimize the medical center's authorized reimbursement for utilization of resources provided.
Compiling, reviewing, abstracting, analyzing and interpreting medical data incidental to a variety of patient care and treatment activities. Conducts daily reviews of all new admissions to designated clinical services to identify those with potential documentation improvements through periodic evaluation during the patient's stay. Reviews the health record and discusses the case with the clinical staff.
Performs admissions reviews for specific patient populations to facilitate appropriate clinical documentation and ensures the level of services and acuity of care are accurately reflected in the health record.
Reviews the appropriateness of patient working Diagnosis Related Group (DRG) and length of stay information by reviewing all clinical documentation, lab results, diagnostic information and treatment to ensure documentation reflects severity of illness, acuity and resource consumption. Other duties as assigned. Work Schedule: Monday - Friday, 8:00 am - 4:30 pm(Note: Work schedules are determined and approved by the supervisor.
The incumbent may be required to work various shifts on a permanent or temporary basis based on facility/patient care needs).
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/.
Desiree.Dellafosse@va.gov · (209) 557-6225
This position is with Veterans Health Administration, Department of Veterans Affairs.
The posted pay range is $65735 – $85460/yr.
This position is eligible for telework.
This position requires a Other security clearance.
Applications close on 2026-09-23.
This position is open under the 'Public' hiring path.
Source: USAJOBS.gov — U.S. Federal Government
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