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.
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.
Experience/Education Combination: Equivalent combinations of experience and education are qualifying.
(a) Successful completion of an associate's 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 U.S. 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 substitute 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.
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 and/or cancer registry practice.
Quality of Experience. 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. Part-time experience as a professional medical record technician is credited according to its relationship to a full-time workweek. For example, a medical record technician would receive 1 week of full-time credit for each 2 weeks of half-time work
FOREIGN EDUCATION REQUIREMENTS: To receive credit for education completed outside the United States, you must show proof that the education has been submitted to a private organization that specialized in interpretation of foreign educational credentials and such education has been deemed at least equivalent to that gained in conventional U.S. education programs.
Note: The Professional Standards Board (a peer-review group) will review the selected candidate's qualifications and recommend the step at which the candidate will be placed. The salary is based on the grade and step approved for the selected candidate. In addition to the basic requirements, to qualify for the following grade level requirements are:
GS-4: None beyond basic requirements
Demonstrated Knowledge, Skills, and Abilities
1. Basic knowledge of medical terminology;
2. Basic knowledge of disease processes and human anatomy;
3. Basic knowledge of medical record/health information guidelines, techniques, and procedures;
4. Knowledge of the medical and legal significance of medical records.
GS-5: Experience: In addition to the basic requirements, at least 1 year of experience equivalent to GS-4 level and must fully meet the KSAs at that level. OR
Education: 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.
Demonstrated Knowledge, Skills, and Abilities
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: Experience: One 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 level and must fully meet the KSAs at that level. In addition, the candidate must demonstrate the following KSAs:
(1) 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;
(2) Knowledge of Joint Commission on Accreditation of Healthcare Organizations (JCAHO) as well as Medicare/Centers for Medicare & Medicaid Services (CMS) and/or VHA medical record documentation requirements;
(3) 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;
(4) Ability to research and solve complex questions related to coding and documentation, such as adequate health information documentation, coding, billing, resident supervision, etc.; and
(5) 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,
GS-8: One year of experience comparable to the GS-7 level. This is considered to be the full performance level for this assignment. Certification at this grade level is highly desired. In addition, the candidate must demonstrate the following KSAs:
a. Demonstrated Knowledge, Skills, and Abilities
(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.
When describing your experience please include your title, duties performed, and dates of employment. We will not make assumptions regarding your experience.
NOTE: Evidence of experience must be supported by detailed documentation on your resume. Also provide work experience information such as hours per week, salary and starting/ending dates of employment (month and year format) to establish one (1) full year of 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 (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: 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.
Note: The Professional Standards Board (a peer-review group) will review the selected candidate's qualifications and recommend the step at which the candidate will be placed. The salary is based on the grade and step approved for the selected candidate