Medical Records Administration Specialist

National Institutes of Health • Montgomery County, MD

11h • Onsite

About The Position

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.

Requirements

• U.S. Citizenship requirement or proof of being a U.S. National must be met by closing date.
• Employment is subject to the successful completion of a background investigation, verification of qualifications, completion of onboarding forms, submission of required documents, and any other job-related requirement before or after appointment.
• Applicants must meet all qualification requirements by the closing date of this announcement.
• Males born after December 31, 1959 must be registered with the Selective Service.
• The National Institutes of Health participates in the USCIS Electronic Employment Eligibility Verification Program (E-Verify).
• The NIH maintains a tobacco free work environment and campus.
• Must be able to perform the essential duties of the position, with or without reasonable accommodation.
• Based on your appointment, a one or two-year trial/probationary period may be required.
• If selected, depending on your official duty location, you may be required to complete a pre-employment medical examination, provide evidence of immunization, and be free from communicable diseases.
• The work is primarily sedentary, although extended periods of standing or walking may be required.
• The work environment involves everyday risks or discomforts which require normal safety precautions typical of offices within a medical research facility.
• Stooping, stretching, and carrying light to moderate weight items such as paper documentation, computer equipment, manuals, and files may be required.
• Flexible, irregular, and/or prolonged work schedules may be required and may occur regularly or intermittently.
• There is adequate light, heat, and ventilation in the work area.
• Maintain health information policy guidelines in accordance with federal and state regulations.
• Enforce Health Insurance Portability and Accountability Act (HIPAA) compliance as it relates to protecting patient privacy and data security.
• Assign International Classification of Diseases (ICD), Current Procedural Terminology (CPT), and Healthcare Common Procedure Coding System (HCPCS) codes based on strict medical terminology guidelines.
• Ensure all medical record entries are properly signed, dated, and reflect history and physical progress notes, and discharge summaries.
• Conduct periodic audits of medical record documentation.
• Review Electronic Health Records (EHRs) for accuracy, regulatory compliance, and complete documentation.
• Analyze trends and track data patterns to generate utilization reports and optimize resource allocation.
• Provide feedback to staff to improve future medical records documentation.
• Recommend changes to EHR software performance, clinical workflows, and internal quality assurance protocols.

Nice To Haves

• 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.

Responsibilities

• 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.

Benefits

• A career with the U.S. government provides employees with a comprehensive benefits package.
• As a federal employee, you and your family will have access to a range of benefits that are designed to make your federal career very rewarding.
• Eligibility for benefits depends on the type of position you hold and whether your position is full-time, part-time or intermittent.
• Contact the hiring agency for more information on the specific benefits offered.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level