This position is located in the Health Information Management (HIM) Section at the Tuscaloosa VA Medical Center and serves as a key member of the Medical Records Technician (MRT) team specializing in Clinical Documentation Improvement (CDI).
The Clinical Documentation Improvement Specialist plays a critical role in ensuring the accuracy, completeness, and integrity of the health record, directly supporting patient care, healthcare operations, compliance, and resource allocation.
Major duties include but are not limited to: Reviews inpatient and outpatient clinical documentation to ensure accuracy, completeness, and support of correct code assignment, severity of illness, and resource utilization.- Conducts concurrent and retrospective documentation reviews; identifies opportunities for clarification and improvement.
Serves as a liaison between HIM and clinical providers, facilitating communication to improve documentation quality and compliance Queries clinicians to clarify ambiguous, incomplete, or conflicting documentation; evaluates responses for accuracy and compliance with coding and documentation standards.
Provides focused education to providers on documentation requirements, E/M coding, CPT/ICD-10 specificity, and the impact of documentation on workload, quality measures, VERA, and reimbursement. Assists in developing, updating, and implementing policies and guidelines related to clinical documentation improvement. Reviews admissions, DRGs, treatment plans, lab results, and diagnostic data to verify documentation reflects patient acuity and clinical conditions.
Participates in interdisciplinary rounds to offer guidance on documentation, coding rules, DRG methodology, and reimbursement considerations. Monitors trends or changes in industry standards, regulations, and coding guidance; identifies training needs and coordinates education with HIMS leadership and other stakeholders.
Collaborates with Provider Auditor and HIMS leadership to ensure accurate provider documentation and compliance with regulatory and accreditation requirements. Maintains documentation review statistics, prepares summary reports, and analyzes data to identify trends, measure program effectiveness, and support leadership decision-making. Ensures provider documentation aligns with national guidelines, VA policy, UHDDS definitions, and ethical coding practices.
Supports internal audits, compliance reviews, and process-improvement initiatives related to documentation, coding accuracy, and billing integrity. Provides technical expertise and guidance on health record documentation issues, including patient confidentiality, informed consent documentation, legal requirements, and record content standards.
Contributes to staff training, orientation of new clinical providers, and intra-departmental education programs to strengthen documentation accuracy and quality. Performs other duties as assigned. Work Schedule: 8:00 a.m. - 4:30 p.m., Monday through Friday Telework: Not Authorized Virtual: This is not a virtual position. Functional Statement #: 63086F 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/.
JANICE.STAKELY@VA.GOV · 2059338101
This position is with Veterans Health Administration, Department of Veterans Affairs.
The posted pay range is $62344 – $81052/yr.
Applications close on 2026-09-18.
This position is open under the 'Fed Internal Search' hiring path.
Source: USAJOBS.gov — U.S. Federal Government
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