Medical Records Administration Specialist
Join NIH's Clinical Center as a Medical Records Administration Specialist and help protect the integrity of the electronic health record while supporting patient care and clinical research. You'll review documentation, apply coding and privacy standards, improve data quality, and collaborate with clinical staff to strengthen health information practices in a unique biomedical research environment. Make a meaningful impact where healthcare, data, compliance, and discovery come together.
Major duties
Review and analyze electronic health record documentation for accuracy, completeness, data integrity, and compliance with applicable requirements. Identify and resolve documentation issues, including missing, duplicate, mis-indexed, or inconsistent medical record information. Assign and review ICD, CPT, and HCPCS codes to accurately capture diagnostic and procedural information. Analyze coding and documentation trends, conduct quality assurance reviews, and recommend corrective actions or training. Collaborate with clinical and administrative staff to improve documentation practices and support accurate, complete medical records. Process requests for medical information and ensure compliance with privacy, legal, and disclosure requirements. Support improvements to electronic health record and document-management workflows, data retrieval, and system enhancements. Maintain and analyze coded clinical data to support reporting, research, resource tracking, and operational decision-making.
Qualifications
You qualify at the GS-09 level, if you meet one of the following qualification requirements: A. You must demonstrate in your resume at least one (1) year of qualifying experience equivalent to at least the GS-07 level in the Federal service obtained in either the private or public sector, performing the following types of tasks: 1. Maintain health information policy guidelines in accordance with federal and state regulations.; 2. Enforce Health Insurance Portability and Accountability Act (HIPAA) compliance as it relates to protecting patient privacy and data security.; 3. Assign International Classification of Diseases (ICD), Current Procedural Terminology (CPT), and Healthcare Common Procedure Coding System (HCPCS) codes based on strict medical terminology guidelines.; 4. Ensure all medical record entries are properly signed, dated, and reflect history and physical progress notes, and discharge summaries.; 5. Conduct periodic audits of medical record documentation. OR B. Completion of a Master's degree in an accredited or pre-accredited college or university; or 2 full years of progressively higher level graduate education leading to such a degree; or possession of an LL.B. or J.D. degree, if related; OR C. A combination of education and specialized experience that meets the qualification requirements for this position. You qualify at the GS-11 level, if you meet one of the following qualification requirements:A. You must demonstrate in your resume at least one (1) year of qualifying experience equivalent to at least the GS-09 level in the Federal service obtained in either the private or public sector, performing the following types of tasks: 1. Review Electronic Health Records (EHRs) for accuracy, regulatory compliance, and complete documentation.; 2. Assign ICD, CPT, and HCPCS codes based on strict medical terminology guidelines.; 3. Analyze trends and track data patterns to generate utilization reports and optimize resource allocation.; 4. Provide feedback to staff to improve future medical records documentation.; 5. Recommend changes to EHR software performance, clinical workflows, and internal quality assurance protocols. OR B. Completion of a Ph.D. or equivalent doctoral degree, or 3 full years of progressively higher level graduate education leading to such a degree or an LL.M., if related; OR C. A combination of education and specialized experience that meets the qualification requirements for this position. You will receive credit for all experience material to the position, including experience gained in religious, civic, welfare, service, and organizational activities, regardless of whether you received pay. Do not copy and paste the duties or specialized experience from this announcement into your resume as that will not be considered a demonstration of your qualifications for this position. We may verify or assess your qualifications at any time. Inflated or unsupported qualifications may affect your rating. Any misrepresentation or material omission of facts may be sufficient cause to end further consideration of your candidacy. Persons listed as knowing your past accomplishments or experience in your application may be contacted for verification purposes at any time. Verification may, but need not, begin before receiving an offer. Preview application questionnaire before you apply: https://apply.usastaffing.gov/ViewQuestionnaire/13070163
Education
If you qualify based on education in lieu of specialized experience, you are strongly encouraged to submit a copy of your transcripts or a list of your courses including titles, credit hours completed and grades. Unofficial transcripts will be accepted in the application packages. Official transcripts will be required from all selectees prior to receiving an official offer. Click here for information on Foreign Education.