This Position Is No Longer Available
  1. Overview
  2. Duties
  3. Qualifications & Evaluations
  4. Benefits & Other Info
  5. How to Apply

Job Title:Medical Record Technician

Department:Department Of Veterans Affairs

Agency:Department of Veterans Affairs - Agency Wide

Job Announcement Number:JP-13-APA-788484

This position is closed and no longer accepting online applications through USAJOBS.

The contents of the announcement can still be viewed.


$35,306.00 to $62,961.00 / Per Year


Friday, November 16, 2012 to Friday, November 30, 2012




Full Time - Permanent




1 vacancy in the following location:
Houston, TX United StatesView Map


All groups of qualified individuals


Vacancy Identification Number (VIN): 788484 

To fulfill President Lincoln's promise – "To care for him who shall have borne the battle, and for his widow, and his orphan" – by serving and honoring the men and women who are America's Veterans. 


How would you like to become a part of a team providing compassionate care to Veterans?


As a VA professional, your opportunities are endless. With many openings in the multiple functions of VA, you will have a wide range of opportunities at your fingertips. Not only is it the largest, most technologically advanced integrated health care system in the nation, but we also provide many other services to Veterans through the Benefits Administration and National Cemeteries.


Special Employment Consideration:  VA encourages persons with disabilities to apply.


NOTE:  GS-675-5/6/7/8 - A Professional Standards Board will determine the selectee’s starting grade level based on the applicant’s education and experience.


  • U. S. Citizenship
  • Must pass pre-employment examination
  • English Language Proficiency required
  • Designated and-or Random Drug Testing required
  • Background and-or Security Investigation required


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This position is in the Health Information Management Section, Michael E. DeBakey VA Medical Center, Houston, Texas.   The Medical Record Technician is responsible for performing quality review of inpatient records and outpatient when needed, assigning of appropriate ICD-9, CPT and HCPCS codes.   Duties and responsibilities include, but are not limited to: Conducts qualitative/quantitative analysis on the medical records to ensure all components parts of the records are present, accurate, and comply with VA and JCAHO requirements; Works closely with members of health care team to perform the coding/QM activities with the highest possible degree of accuracy; Provides technical advice to the professional staff relative to the best method of recording diagnoses and operations; Recommends inclusion of diagnosis identified through review of the records that have not been documented on the electronic progress note/encounter form and/or discharge note/summary; Codes diagnoses, operations and procedures (inpatient and outpatient), which requires the incumbent to be knowledgeable in a variety of coding systems and   ensuring completeness and conformance to accepted VA Regulations, JCAHO Requirements, ICD-9-CM coding conventions, and guidelines for optimal Diagnostic Related Group (DRG) assignment; Incumbent is responsible for communicating on a continual basis with physicians and other pertinent clinical personnel; maintains current knowledge of the PTF abstracting system, ICD-9-CM coding rules, CPT ambulatory coding rules, and current VA and JCAHO standards for complete medical records; Provides technical staff support to the Administrative Assistant, Chief HIMS, Supervisor, Coding Unit, Data Validator, MRT and Chief, HIMS for the administration of the medical center's health information management program; and other duties as assigned.


Tour of Duty: Monday - Friday: 7:30am - 4:00pm OR Monday-Friday 8:00am - 4:30pm




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  • U.S. citizenship.  
  • Experience and Education

(1) Experience. Two years of experience that demonstrates the applicant's ability to perform the work, or provides familiarity with the work. Six months of the required 2 years of experience must have provided the knowledge, skills, abilities, and other characteristics (KSAs) needed to perform MRT work.


(2) Education. Successful completion of an associate's degree with a major field of study in medical record technology/health information technology which was accredited by the American Health Information Management Association (AHIMA) at the time the program was completed.


(3) Experience/Education Combination. Equivalent combinations of experience and education are qualifying.



GS-5: ExperienceIn addition to the basic requirements, at least 1 year of experience at the next lower grade level and must fully meet the KSAs at that level.

OR EducationSuccessful completion of a baccalaureate degree from an accredited college or university with a major field of study in medical record technology/health information technology or a related degree with courses related to medical record technology sufficient to evidence the core competencies identified.


In addition, the candidate must demonstrate the following KSAs:

1.   Ability to apply knowledge of medical terminology, human anatomy/pathophysiology, and disease processes sufficient to appropriately file, locate, and disclose health information;

2.   Ability to correctly apply a practical knowledge of laws and regulations related to the confidentiality of health information and the release of information from medical records;

3.   Knowledge of the internal organization of medical records and medical record references and procedures as appropriate to the position.

4.   Ability to use health information software appropriate to the position, such as the electronic patient record, record tracking systems, chart deficiency systems, coding and abstracting systems, release of information systems, document scanning technology, electronic spreadsheets, transcription systems, encoder products, electronic encounter forms, database software, etc.


GS-6:  ExperienceOne year of experience comparable to the GS-5 level and must fully meet the KSAs at that level. In addition, the candidate must demonstrate the following KSAs:

1. Ability to apply knowledge of medical terminology, human anatomy/pathophysiology, and disease processes to fully understand the content of a patient record;

2. Ability to navigate efficiently through the paper and electronic medical record to find needed information;

3. Skill in interpreting and adapting health information guidelines that are not completely applicable to the work or have gaps in specificity and ability to use judgment in completing assignments with incomplete or inadequate guidelines;

4. If assigned to medical record analysis, ability to judge whether medical records contain sufficient information for regulatory requirements; are acceptable as legal documents; are adequate for continuity of patient care; and support education and research needs. This includes the ability to take appropriate actions if medical record contents are not adequate; accurate, timely, and/or reliable;

5. Ability to apply laws and regulations on the confidentiality of health information (e.g., Privacy Act, Freedom of Information Act, Health Insurance Portability and Accountability Act (HIPAA);

6. If assigned to a tumor registry position, ability to apply guidelines and standards for the maintenance of an approved tumor registry; and

7. If assigned to a medical coding position, comprehensive knowledge of classification systems, such as current versions of International Classification of Diseases (ICD), Current Procedural Technology (CPT), the Systematized Nomenclature of Medicine (SNOMED) or Healthcare Common Procedure Coding System (HCPCS), and skill in applying coding knowledge.


GS-7:  Experience:  One year of experience comparable to the GS-6 grade level and must fully meet the KSAs at that level.  In addition, the candidate must demonstrate the following KSAs: 

(1) In-depth knowledge of professional registry practices;

(2) In-depth knowledge of fundamental tumor registry operations;

(3) Ability to analyze data using comparative statistical methods and present the data in graphic format;

(4) Experience in meeting the standards of external approving bodies;

(5) Ability to communicate with, and advise, clinical staff about registry operations, statistical reports, and the standards of approving bodies; and

(6) Ability to manage priorities and coordinate work in order to complete duties at the assigned grade level in an accurate and timely fashion; ability to follow-up on pending issues; and demonstrated understanding of the impact of incomplete work.


GS-8:  Experience: One year of experience comparable to the GS-7 grade level for the appropriate assignment area and must fully meet the KSAs at that level.

In addition, the candidate must demonstrate the following KSAs:

(1)   Ability to analyze the medical record to identify all pertinent diagnoses and procedures for coding, and to evaluate the adequacy of the documentation.   This includes the ability to read and understand the content of the medical record, the terminology, the significance of the comments, and the disease process/pathophysiology of the patient;

(2)   Skill in reviewing medical record documentation and assigning current versions of the classification systems required in the current position, such as ICD and CPT; and

(3)   Advanced knowledge of the full scope of coding and abstracting including inpatient discharges, surgical cases, diagnostic studies and procedures, outpatient encounters, and inpatient professional fees for a highly diversified range of specialties and subspecialties, such as orthopedics, neurosurgery, cardiology, gastroenterology, plastic surgery, spinal cord injury, blind rehabilitation, anesthesia, acute and long term psychiatry including addiction treatment, hospice, ambulatory surgery, and other types of care.



References: VA Handbook 5005/15, Part II, Appendix G35, Medical Records Technician QUALIFICATION STANDARD , dated March 17, 2006.

APPLICANTS PLEASE NOTE:  Education must be accredited by an accrediting institution recognized by the U.S. Department of Education in order for it to be credited towards qualifications (particularly positions with a positive education requirement.)  Therefore, applicants must report only attendance and/or degrees from schools accredited by accrediting institutions recognized by the U.S. Department of Education.  Applicants can verify accreditation at the following website: All education claimed by applicants will be verified by the appointing agency accordingly.  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.

Veterans' Preference:

When applying for Federal Jobs, eligible Veterans should claim preference on their application or résumé. Applicants claiming preference based on service-connected disability, or based on being the spouse or mother of a disabled or deceased Veteran, must complete an SF 15, Application for 10-Point Veteran Preference. Veterans who are still in the service may be granted tentative preference on the basis of information contained in their applications, but they must produce a DD Form 214 or other proof prior to appointment to document entitlement to preference.  For more information on Veterans' Preference, please visit


You will be evaluated based on the detailed information submitted in your resume that reflects your knowledge, skills, and ability necessary to meet the qualification of this position.  Although you are not required to submit essay-style responses to the individual KSAs specifically in your initial resume/application package, your resume should contain enough detailed information to reflect the fact that you possess the following KSAs:

1. Knowledge of a variety of coding systems using the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM), Current Procedural Terminology Level I (CPT), Health Care Common Procedure Coding System (HCPCS) Level II etc.

2. Knowledge of disease processes, ICD-9-CM coding principles, Medicare Prospective Payment System for Ambulatory Payment Classification (APC's) and Diagnostic Related Groups (DRG's).

3. Knowledge of health information management procedures and techniques, medical terminology, anatomy and physiology, pathophysiology and pharmacology.

4. Knowledge of the internal organization of patient record.

5. Ability to communicate both orally and in writing with people from varied backgrounds.

6. Knowledge of computerized information systems in order to access and analyze data, i.e., DHCP/VISTA.


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Working for the Department of Veterans Affairs offers a comprehensive benefits package that includes, in part, paid vacation, sick leave, holidays, life insurance, health benefits, thrift savings plan, and participation in the Federal Employees Retirement System. In addition to traditional "dollars and cents" benefits, we offer a range of benefits to help balance work and life.  For more information please visit us at



This job opportunity announcement may be used to fill additional vacancies.


This position is in the Excepted Service and does not confer competitive status. 

Receiving Service Credit for Earning Annual (Vacation) Leave:  Federal Employees earn annual leave at a rate (4, 6 or 8 hours per pay period) which is based on the number of years they have served as a Federal employee.   VA may offer newly-appointed Federal employees credit for their job-related non-federal experience or active duty uniformed military service.  This credited service can be used in determining the rate at which they earn annual leave.


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To begin the process, click the Apply Online button at the right side of this screen to create an account or log in to your existing USAJOBS account. Follow the prompts to complete the occupational questionnaire. Please ensure you click the Submit My Answers button at the end of the process.



You may upload the completed form to your USAJOBS or Application Manager account if you apply online.  Then you can use the uploaded form again and again when applying for future vacancies.  Please see this guide ( for more information on uploading and re-using the form in your applications.  Other required forms and documents can also be saved in your account and used the same way.  Applicants are urged to apply online; this process is much easier and faster.

Note: To return to a previously Saved or Incomplete application, just reapply through your account in USAJOBS.  Check your account ( ) to see the status of your application after applying, including any messages that may have been sent to you.

If you cannot apply online:

  1. Click the following link to view and print the occupational questionnaire: View Occupational Questionnaire.
  2. Print this 1203FX form to provide your response to the occupational questionnaire:
  3. Fax the completed 1203FX form along with all supporting documents to (478)757-3144.  Your 1203FX form must be placed on top of all materials being faxed and will serve as a cover page for your fax transmission.
  4. Keep a copy of your fax receipt in case verification is needed.

To fax supporting documents you are unable to upload:

  1. Complete this cover page using the following Vacancy ID: 788484.  You must use this fax cover sheet in order for your documents to be matched with your online application.
  2. Fax your documents to (478)757-3144.

The complete Application Package must be submitted by 11:59 PM (EST) on Friday, November 30, 2012.


You must provide a complete Application Package which includes:

  1. CV or Resume.
  2. VA Form 10-2850c - Application for Associated Health Occupations (Available at (required).
  3. Occupational Questionnaire
  4. Optional Form 306 - Declaration for Federal Employment (Available at  This is a required form and must be submitted with your application.
  5. If prior military service, include all copies of your DD Forms 214 (required).   Applicants claiming preference based on service-connected disability, or based on being the spouse or mother of a disabled or deceased Veteran, must also complete and submit an SF 15, Application for 10-Point Veteran Preference (available at  
  6. If currently employed in the VA system, include latest SF-50 - Notification of Personnel Action. (required).


Human Resources
Phone: (713)794-7458
Agency Information:
Health Information Management Service
2002 Holcombe Blvd
Houston, TX


After we receive your complete application package (including any required documents), your qualifications will be reviewed to decide if you meet the basic requirements.  You will be notified when this decision is made.

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