Medical Record Technician - (ROI-Legal)

Full Job Description

This position is located in the Health Information Management (HIM) section at the Wilmington VA Medical Center.

The MRT (ROI) reviews and processes requests for patient protected health information, provides direct customer service to the Veteran (or third party), by providing copies of the Veteran's PHI, and ensures that only the information that the Veteran specified be released, is shared only with those whom is authorized, or who have legal authority to receive such information.

Applicants pending the completion of educational or certification/licensure requirements may be referred and tentatively selected but may not be hired until all requirements are met.

Basic Requirements: United States Citizenship: Non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy.

Experience and Education (1) Experience. One year of creditable experience that indicates knowledge of medical terminology and general understanding of health records.

Six months of the required one year of creditable experience must have provided the knowledge, skills, and abilities (KSAs) needed to perform MRT (ROI) work. OR (2) Education.

An associate's degree from an accredited college or university recognized by the U.S.

Department of Education with a major field of study in health information technology/health information management, or a related degree with a minimum of 12 semester hours in health information technology/health information management (e.g., courses in medical terminology, anatomy and physiology, legal aspects of health care, and introduction to health records).

OR (3) Experience/Education Combination. Equivalent combinations of creditable experience and education are qualifying towards meeting basic experience requirements.

The following experience and educational/training substitutions are appropriate for combining education and creditable experience: (a) Six months of creditable experience that indicates knowledge of medical terminology, privacy and release of information, the health record, and one year above high school with a minimum of six semester hours of health information technology/health information management courses.

(b) Six months of creditable experience that indicates knowledge of medical terminology, privacy and release of information, the health record, and 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.

The training program may be substituted on a month-for-month basis for up to six months of experience provided the training program included courses in anatomy and physiology, and health record techniques and procedures.

English Language Proficiency. MRTs (ROI) must be proficient in spoken and written English, as required by 38 U.S.C. 7403(f).

May qualify based on being covered by the Grandfathering Provision as described in the VA Qualification Standard for this occupation (only applicable to current VHA employees who are in this occupation and meet the criteria).

All persons employed in VHA as a MRT (ROI) on the effective date of this qualification standard are considered to have met all qualification requirements for the grade held, including positive education and licensure/certification/ registration that are part of the basic requirements of the occupation.

Employees who do not meet all the basic requirements in this standard, but who met the qualifications applicable to the position at the time they were appointed to it, the following provisions apply: (1) Such employees in an occupation that does not require a licensure/certification/ registration may be reassigned, promoted, or demoted within the occupation, but will not be promoted beyond the journey level or placed in supervisory or managerial positions.

(2) Employees who are appointed on a temporary basis prior to the effective date of the qualification standard may not have their temporary appointment extended, or be reappointed on a temporary or permanent basis, until they fully meet the basic requirements of the standard.

(3) Employees initially grandfathered into this occupation, who subsequently obtain additional education and/or licensure/certification/registration that meet all the basic requirements of this qualification standard, must maintain the required credentials as a condition of employment in the occupation.

Medical Records Technician (ROI),GS-7-Experience: To be eligible for the GS 7 Medical Records Technician (MRT) Release of information (ROI) Legal applicants must posses one (1) year of specialized experience equivalent to the next lower grade level GS 6.

Specialized experience can be described as but not limited to: applying, interpreting, and analyzing laws and regulations related to the disclosure of health information.

MRTs (ROI), educating requestors on requirements for submitting requests for health information, receiving and validating authorization forms and requests for information and prioritizing requests according to policies and regulations, using various computer applications to track and release all authorized release of information requests, processing and releasing health information to authorized first- and third party requestors, initiating and maintaining the accounting of disclosure for all records disclosed from a Privacy Act system of records, communicating with internal and external stakeholders to provide technical expertise regarding the release of information process, ensuring compliance with policies, procedures, laws, and regulations governing privacy and release of information.

AND Demonstrated Knowledge, Skills, and Abilities.

In addition to the experience above, the candidate must demonstrate all of the following KSAs: (a) Knowledge of the laws and regulations related to the authorization and disclosure of health information.

(b) Ability to apply laws and regulations related to the disclosure of health information (e.g., Privacy Act, Freedom of Information Act, HIPAA, and 38 U.S.C.

§ 7332, Confidentiality of Certain Medical Records).

(c) Ability to investigate the contents of paper and electronic health records and systems that contain health information to compile the legal health record based on existing standards and requirements.

Reference: For more information on this qualification standard, please visit https://www.va.gov/ohrm/QualificationStandards/. Major Duties:

Duties include but not limited to the following: Provides direct customer service to the Veteran (or third party), by providing copies of the Veteran's PHI, when a signed, written request is received, or upon the Veteran's valid authorization to a third party.

Must possess expertise in all applicable Federal laws, rules, and regulations regarding release of health information.

Serve as the sole point of contact, and accurately process and timely respond to complex medical legal requests, including, but not limited to, subpoenas, depositions, testimony, tortfeasor (Third Party Liability), Workers' Compensation, Labor and Industries, and court orders for information from attorneys, courts, local law enforcement agencies, public defenders, or insurance agencies.

Serve as a liaison to Regional Counsels and U.S. Attorney's offices, for trial cases. Review and analyze requests to ascertain the type of case to be developed.

MRTs (ROI -Legal) ensure all disclosures are made in compliance with existing policies, procedures, guidelines, laws, and regulations.

Ensure that information released is limited to what is specifically authorized and to the person or agency designated to receive it. Maintain the accounting of disclosures for all leg al cases.

Compile the legal health record and provide advisory and technical assistance to patients and internal and external stakeholders pertaining to medical legal requests.

Extensively research and resolve conflicting or inconsistent information related to complex medical legal requests Processes all incoming requests to the facility for Release of Information (ROI) along with information required by the VA Regional Office through the Automated Medical Information Exchange (AMIE).

Compiles tort cases for the Regional Office.

Interviews veterans and insurance agents requesting information for Third Party Liability, Workman's Compensation, and Privacy Act cases for referral to Medical Cost Recovery and/or the Regional Counsel's Office.

Responds to questions from patients concerning services. Searches records or files to compose responses, including electronic searches, to retrieve and summarize hard-to-locate data.

Work Schedule: Monday through Friday, 8:00am to 4:30pm Telework: Not available Virtual: This is not a virtual position.

Position Title/Functional Statement #:Medical Record Technician - (ROI-Legal)/PD000000 Relocation/Recruitment Incentives: Not authorized Financial Disclosure Report: Not required Physical Requirements: The work is primarily a sedentary position.

Typically, the employee sits comfortably to do the work. But, there may be some walking, standing, bending, carrying of light items such as papers, books, small items, etc.

No special physical demands are required to perform the work.

Concentration and sustained performance under potential stress of accuracy and deadlines is required because of factors involved in completion of various complex work assignments.