Citizenship: Citizen of the united States.
English Language Proficiency: Medical Record Technicians must be proficient in spoken and written English.
Certification: Certification is highly desirable at all grade levels. Certification is offered by AHIMA as a Certified Coding Associate (CCA), Certified Coding Specialist (CCS), Certified Coding Specialist-Physician-based (CCS-P), or Registered Health Information Technician (RHIT). Certification is also offered by the American Academy of Professional Coders (AAPC) as a Certified professional Coder Apprentice (CPC-A), Certified Professional Coder-Hospital Apprentice (CPC-H-A), Certified Professional Coder (CPC) or Certified Professional Coder-Hospital (CPC-H).by AHIMA or AAPC as a Certified Coder.
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 Medical Record Technician (MRT) work; OR
Education: Successful completion of an associate 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; OR
Experience/Education Combination: Equivalent combinations of experience and education are qualifying. The following educational/training substitutions are appropriate in this provision for combining education and experience: (a) Successful completion of an associate degree in a field of study other than medical records/health information will substitute for 18 months of the required experience; (b) Successful completion of a course for medical technicians, hospital corpsmen, medical service specialists, or hospital training, obtained in a training program given by the Armed Forces or the US Maritime Service under close medical and professional supervision, may be substituted on a month-for-month basis for up to 1 year of experience; (c) Successful completion of a post high school course of study in medical record technology, which includes courses in anatomy, physiology, and medical record techniques and procedures, may be substituted on a month-for-month basis for up to 1 year of experience; (d) Successful completion of post high school courses for medical administrative personnel, obtained in a closely supervised training program given by the Armed Forces, may be substituted for experience on a month-for-month basis for up to 6 months provided the training program included courses in anatomy, physiology, and medical record techniques and procedures.
DOCUMENTATION IS REQUIRED IF YOU ARE QUALIFYING BASED ON EDUCATION.
For GS-4: Experience OR Education: None beyond the basic requirements as noted above. Candidates must demonstrative a basick nowledge of medical terminology; basic knowledge of disease processes and human anatomy; basic knowledge of medical record/health information guidelines, techniques, and procedures; and knowledge of medical and legal significant of medical records.
For GS-5, GS-6, GS-7, OR GS-8: In addition to the basic requirements noted above, the following criteria must be met:
For GS-5: 1 year of MRT (Medical Record Technician) or related experience equivalent to at least GS-4 grade level OR Successful 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 below:
- Ability to apply knowledge of medical terminology, human anatomy/pathophysiology, and disease processes sufficient to appropriately file, locate, and disclose health information;
- 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;
- Knowledge of the internal organization of medical records and medical record references and procedures as appropriate to the position;
- 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.
For GS-6: 1 year of MRT or related experience equivalent to at least the GS-5 grade level and must demonstrates the following KSAs:
- Ability to apply knowledge of medical terminology, human anatomy/pathophysiology, and disease processes to full understand the content of a patient record;
- Ability to navigate efficiently through the paper and electronic medical record to find needed information;
- 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.
- 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);
- 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.
For GS-7: 1 year of MRT or related experience equivalent to at least the GS-6 grade level and must demonstrate the following KSAs:
- Knowledge of classification systems, such as current versions of ICD, CPT, SNOMED or HCPCS, and skill in applying coding knowledge to a wide range of specialty areas;
- Knowledge of Joint Commission on Accreditation of Healthcare Organizations (JCAHO) as well as Medicare/Centers for Medicare and Medicaid Services (CMS) and/or VHA medical record documentation requirements;
- Ability to communicate with clinical staff on coding and documentation issues such as recording inpatient and outpatient diagnoses and procedures, the use of encounter forms, the correct sequencing of diagnoses/procedures, and/or the relationship between health care documentation and code assignment;
- Ability to research and solve complex questions related to coding and documentation, such as adequate health information documentation, coding, billing, resident supervision, etc.; and
- Skill in reviewing and correcting system or processing errors, reviewing transmission reports, and ensuring all assigned episodes are complete and accurate as appropriate to the duties assigned.
NOTE: Medical Record Technician Coding assignments at this level (GS-7) represent the advanced developmental level leading to the full performance level. It is expected that the medical coder will do more than validate code assignments made by clinical staff, but will have the skill to make independent judgment in selection of codes based on medical documentation and personal coding knowledge and skill. Reviewing codes selected by physicians/health care providers or reviewing entries on an encounter form or superbill is not considered comprehensive coding and, without the demonstration of additional skills, is not acceptable to achieve this level.
For GS-8: 1 year of MRT experience comparable to the next lower grade level and must demonstrate the following KSAs:
- 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;
- 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
- Advanced knowledge of the full scope of coding and abstracting including inpatient discharges, surgical cases, diagnostic studies and procedures, outpatient encounters, and the inpatient professional fees for a highly diversified range of specialties and subspecialties, such as orthopedics, cardiology, gastroenterology, blind rehabilitation, anesthesia, acute and long term psychiatry including addiction treatment, hospice, ambulatory surgery, and other types of care.
NOTE: Creditable Experience: Applicants must demonstrate knowledge of current Medical Record Technology. To be creditable, the experience must have required the use of knowledge, skills, abilities and other characteristics associated with current health information or medical record technology. Experience is only creditable if it is either directly related to the position to be filled or in a related field. Qualifying experience must also be at a level comparable to medical record technology experience at the next lower grade level. Part time experience as a professional medical record technician is credited according to its relationship to a full time workweek.
IN DESCRIBING YOUR EXPERIENCE, PLEASE BE CLEAR AND SPECIFIC. WE MAY NOT MAKE ASSUMPTIONS REGARDING YOUR EXPERIENCE.
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. Applicants must, therefore, only report 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: http://www.ed.gov/admins/finaid/accred/index.html. 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. ***
TIME IN GRADE RESTRICTION DOES NOT APPLY TO THIS HYBRID OCCUPATION
HOW YOU WILL BE EVALUATED:
Your application, résumé and/or supporting documentation will be verified. Please follow all instructions carefully. Errors or omissions may affect consideration for employment. You may also be evaluated based upon the question responses you provide during a structured interview. In responding to structured interview questions you should be sure to cite specific examples of experience, explain exactly what you did, and the outcome.