Clinical Documentation Integrity (CDI) Medical Records Technician

The CDI Medical Records Technician plays a critical role in enhancing the quality and accuracy of clinical documentation within the Veterans Health Administration (VHA) system. This position is based onsite at the Lt. Col. Luke Weathers, Jr. VA Medical Center in Memphis, TN, a high-complexity, tertiary care teaching hospital serving over 206,000 veterans across Tennessee, Arkansas, and Mississippi. As a Medical Records Technician (MRT) specializing in Clinical Documentation Integrity, you will collaborate with healthcare providers, coding professionals, and clinical staff to ensure that medical records accurately reflect the patient’s clinical status, diagnoses, and treatment plans. Your work will directly impact coding accuracy, reimbursement, quality reporting, and patient care outcomes. Key Responsibilities: Perform concurrent and retrospective reviews of inpatient and outpatient medical records to identify documentation gaps and opportunities for improvement. Initiate and manage provider queries to clarify ambiguous, incomplete, or conflicting documentation. Apply knowledge of ICD-10-CM coding, SNOMED-CT terminology, and VHA documentation standards to support accurate coding and billing. Assist in the development and implementation of CDI workflows, SOPs, and training programs. Educate providers and staff on documentation best practices, compliance standards, and regulatory requirements. Participate in reconciliation processes to resolve discrepancies between CDI and final coded records. Support quality initiatives including mortality reviews, CMS core measures, and utilization management. Maintain compliance with VA, CMS, and Joint Commission documentation guidelines. Work Environment: Onsite at a Level 1A VA Medical Center with a 60-bed Spinal Cord Injury Unit and 10 outpatient clinics. Collaborative, multidisciplinary team setting under the supervision of the Chief of Health Information Management. Job Details Position Type: Full-Time (Onsite) Location: Lt. Col. Luke Weathers, Jr. VA Medical Center, 116 North Pauline Street, Memphis, TN 38104 Period of Performance: Base Year (Oct 1, 2025 – Sep 30, 2026) with one (1) Option Year Work Schedule: Monday to Friday, 7:30 AM – 4:00 PM EST Service Contract Act Applicable: Yes Hourly Rate: $27.20-$33 Per Hour + SCA Health and Welfare (H&W) $5.09 Per Hour Citizenship Requirement: U.S. Citizen or Green Card holder Requirements Education: Bachelor’s degree preferred; Master’s degree optional Experience: Minimum of 2 years of recent CDI experience in trauma, teaching, or tertiary hospital settings Certifications: Must hold current certification from one or more of the following: ACDIS (Association of Clinical Documentation Integrity Specialists): Certified Clinical Documentation Specialist (CCDS)) AHIMA (American Health Information Management Association): Certified Documentation Integrity Practitioner (CDIP) AAPC (American Academy of Professional Coders): Certified Documentation Expert Outpatient (CDEO) certification or Certified Documentation Expert Inpatient (CDEI) certification Technical Skills: Proficient in reviewing inpatient and outpatient documentation, applying ICD-10-CM coding standards, and using SNOMED-CT terminology Responsibilities: Conduct concurrent and retrospective reviews of medical records Collaborate with providers to clarify documentation Develop SOPs, workflows, and training materials Participate in reconciliation of CDI and coding discrepancies Educate staff on documentation standards and compliance Compliance: Must meet all VA, CMS, and Joint Commission documentation guidelines Health Requirements: Must provide proof of current immunizations and screenings (TB, MMR, Varicella, Tdap, Influenza, COVID-19) Other Requirements: Must pass background check and credentialing Must maintain PHI access and NPI registration Must adhere to ACDIS Code of Ethics Benefits Comprehensive Health & Wellness Coverage Medical Coverage: Multiple nationwide and regional options, including HMO, PPO, and HDHP plans, with access to 24/7 telemedicine and wellness programs. Dental & Vision Insurance: Preventive, basic, and major dental services, plus vision exams, frames, and contact lenses. Health Savings Account (HSA) & Flexible Spending Account (FSA): Pre-tax savings for healthcare expenses. Employee Assistance Program (EAP): Confidential support for mental health, legal consultations, and work-life balance. Financial Wellbeing 401(k) Retirement Plan with Employer Matching. Financial Coaching: Budgeting tools and financial planning support. Commuter Benefits & Adoption Assistance: Savings on mass transit and reimbursement for eligible adoption expenses. Work-Life Balance & Professional Growth Training & Development: Access to on-demand courses and professional growth programs. Sick Time and PTO Holiday Pay Additional Perks MarketPlace™ Perks at Work: Discounts on fitness, nutrition, travel, and childcare. Community Online Academy: Free wellness and professional development courses.