The Medical Records Technician (Clinical Documentation Improvement Specialist) - Inpatient/Outpatient, GS-09, serves within the Health Information Management Service (HIMS) and is responsible for improving the overall quality, accuracy, completeness, and timeliness of clinical documentation in the health record.
The Medical Records Technician (Clinical Documentation Improvement Specialist) - Inpatient/Outpatient collaborates with providers, nurses, coders, and other healthcare professionals to ensure documentation accurately reflects patient severity of illness, quality of care, resource utilization, and regulatory requirements.
This position reviews medical records, identifies documentation deficiencies, provides education and guidance to clinical staff, and promotes compliance with coding, documentation, and reimbursement standards. The position directly supports patient care initiatives, performance improvement efforts, coding accuracy, data integrity, and organizational goals through effective clinical documentation improvement practices.
Major Duties Reviews inpatient and outpatient medical records to identify opportunities for clinical documentation improvement. Collaborates with physicians, nurses, coders, and other healthcare staff to clarify and improve documentation accuracy. Analyzes health record documentation to ensure completeness, specificity, and compliance with regulatory requirements.
Conducts concurrent and retrospective reviews of patient records to support accurate code assignment and reimbursement. Provides education and training regarding documentation standards, coding guidelines, and clinical documentation improvement initiatives. Monitors changes in coding regulations, documentation requirements, and industry standards and communicates impacts to stakeholders.
Assists with policy development and process improvement activities related to documentation integrity and compliance. Evaluates documentation to support accurate assignment of diagnoses, procedures, severity of illness, risk of mortality, and quality measures. Performs clinical documentation audits, data analysis, and reporting to identify trends and opportunities for improvement.
Participates in multidisciplinary rounds and serves as a clinical documentation resource for healthcare teams. Maintains documentation improvement databases and prepares reports for leadership and program oversight. Ensures compliance with VA policies, coding guidelines, privacy requirements, and health information management standards. Work Schedule: 8:00am - 4:30pm; Monday - Friday Telework: Not Available Virtual: This is not a virtual position.
Functional Statement #: 40410F Relocation/Recruitment Incentives: Not Authorized ***THIS IS NOT A VIRTUAL POSITION, YOU MUST LIVE WITHIN OR BE WILLING TO RELOCATE WITHIN A COMMUTABLE DISTANCE OF THE DUTY LOCATION***
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/.
Paula.Velez@va.gov · 813-816-7155 X100173
This position is with Veterans Health Administration, Department of Veterans Affairs.
The posted pay range is $65735 – $85460/yr.
Applications close on 2026-11-13.
This position is open under the 'Fed Internal Search' hiring path.
Source: USAJOBS.gov — U.S. Federal Government · Retrieved 2026-11-03 · Not affiliated with or endorsed by OPM or USAJOBS.gov
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