Medical Records Technician (CDIS In/Out)

U.S. Department of Veterans Affairs

Atlanta (GA)

Remote

USD 65,000 - 85,000

Full time

4 days ago

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Job summary

U.S. Department of Veterans Affairs is seeking a Medical Records Technician (Coders) at the VA Medical Center in Atlanta, GA.

The role focuses on classifying medical data from patient health records by assigning alpha-numeric codes for diagnoses and procedures, with emphasis on documentation quality and coding accuracy. Incumbents will review clinical documentation, educate staff, and coordinate between HIM and clinical teams to ensure complete and accurate health records, aligning with VERA

Qualifications

Knowledge of medical terminology, anatomy, physiology and disease processes.
Familiarity with health services and coding conventions to ensure accurate coding.
Ability to educate and liaise with clinical staff on documentation and coding practices.

Responsibilities

Review the overall quality and completeness of clinical documentation.
Provide education to clinical staff on documentation for inpatient and outpatient care.
Educate providers on documentation needs and the impact on coding, workload and reimbursement.
Coordinate between health information management and clinical staff to improve documentation quality.
Review documentation to ensure accurate severity of illness, risk of mortality, and resource use.
Query clinical staff to clarify ambiguous documentation and drive corrective actions.
Assist with seminars and trainings on health record documentation.

Skills

Medical terminology

Anatomy & physiology

Documentation quality

Coding practices

Job description

Department: Department of Veterans Affairs

This position is located in the Health Information Management (HIM) Section, under the Business Office, at the VA Medical Center, Atlanta, Ga. Medical Records Technicians (Coders) are skilled in classifying medical data from patient health records. These coding practitioners analyze patients' health records and assign alpha-numeric codes for each diagnosis and procedure.

Key Responsibilities

Major Duties Include but are not limited to: Reviewing the overall quality and completeness of clinical documentation. Applying 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 to ensure proper code selection.

Reviewing clinical documentation and providing education to clinical staff on inpatient and outpatient episodes of care. Preparing and conducting provider education on documentation processes in the health record to include the impact of documentation on coding, workload, quality measures, reimbursement, and funding.

Providing education to providers on the need for accurate and complete documentation in the health record, ensuring documentation supports the codes selected to the highest degree of specificity. Adhering to accepted coding practices, guidelines, and conventions to ensure ethical, accurate, and complete coding. Ensuring provider documentation is complete and supports the diagnoses and procedures coded.

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. 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. Obtains appropriate corrective action plans from responsible clinical service directors and recommend improvements or changes in documentation practices, when applicable.

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.

Incumbent develops and conducts seminars, workshops, short courses, informational briefings, and conferences concerned with health record documentation, educational and functional training requirements to ensure program objectives are met for clinical and Health Information Management (HIM) staff. Work Schedule: Full-time, Monday-Friday, 8:00am-4:30pm. (Subject to change based on agency need.) Telework: 5 Days per pay period Virtual: This is not a virtual position.

Functional Statement #: 60956F Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized

Requirements & Education

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/.

Which agency is hiring for this position?

This position is with Veterans Health Administration, Department of Veterans Affairs.

What is the salary for this position?

The posted pay range is $65271 – $84857/yr.

Is this position remote or telework eligible?

This position is eligible for telework.

What security clearance is required?

This position requires a Other security clearance.

What is the application deadline?

Applications close on 2026-10-30.

Who is eligible to apply?