The Medical Records Technician (Clinical Documentation Improvement Specialist) reviews inpatient and outpatient medical records to ensure diagnoses, conditions, and procedures are fully and accurately documented. The role supports clinical documentation quality, coding accuracy, reimbursement, and regulatory compliance within the Health Information Management section at the Kansas City VA Medical Center.
Key duties include reviewing documentation for completeness and quality, analyzing records and encounter forms, educating clinical staff on documentation practices, monitoring coding and policy requirements, and developing educational sessions and training for providers and staff.
Basic requirements
- U.S. citizenship required
- Proficiency in written and spoken English
- One year of creditable experience in medical terminology, anatomy and physiology, pathophysiology, medical coding, and health record structure; or an eligible associate's degree; or completion of an approved coding program; or an approved experience/education combination
- Required certification: mastery-level certification through AHIMA or AAPC, or a clinical documentation improvement certification
GS-9 requirements
- One year of experience equivalent to GS-8 as an MRT (Coder), or
- Associate's degree or higher plus 3 years of CDI experience, or
- Mastery-level certification plus 2 years of CDI experience, or
- Clinical experience such as RN, MD, or DO plus 1 year of CDI experience
Knowledge and skills
- Knowledge of coding and documentation guidelines
- Knowledge of anatomy, physiology, pathophysiology, and pharmacology
- Ability to analyze data and present findings
- Strong verbal and written communication skills
- Knowledge of healthcare documentation regulations and coding systems including ICD-CM, PCS, CPT, HCPCS, MS-DRG, and POA indicators
- Ability to provide training and education to staff
Benefits
- Competitive salary and regular salary increases
- Telework available per agency policy
- Federal retirement plan with pension and 401(k) match
- Federal health, vision, dental, life, and long-term care insurance
- Paid time off and federal holidays
- Paid parental leave after 12 months of employment
- Child care subsidy may be available
- Opportunity for annual leave accrual credit based on prior service
Location
Kansas City, Missouri, US
Employment Type
Full-time
Experience Level
Associate
Salary Range
$62,729 - $81,553
Remote work allowed
Yes
Posted
1 week ago