MEDICAL RECORDS TECH (HIT)

Full Job Description

This position is located in the Health Information Management (HIM) section at the William S. Middleton Memorial VA Hospital. MRTs HIT perform incomplete health record analysis.

They review, analyze, abstract, maintain, extract, and compile information from the health record.

MRTs HIT check for accuracy, completeness, and timeliness of the health record and monitor and report for regulatory compliance.

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, anatomy, physiology, and a 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 HIT 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, 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 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.

3 (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 U.S.

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 six months of experience, provided the training program included courses in anatomy, physiology, and health record techniques and procedures.

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).

Grade Determinations: GS-0675-04: (1) Experience or Education. None beyond basic requirements. (2) Assignment.

Employees at this level serve as entry level MRTs HIT, and receive close supervision from the supervisory MRT HIT or designee.

MRTs HIT analyze health records for accuracy, completeness, timeliness, consistency, and compliance (e.g., scanned, uploaded, use of correct titles, linked to correct encounters, etc.), with HIM industry standards, policies, procedures, laws, regulations, and accrediting bodies.

They perform health record review activities to satisfy external accreditation requirements and medical center performance measures.

They monitor, verify, correct, and upload all transcription/medical speech recognition to maintain completeness and accuracy of health records. GS-0675-05: (1) Experience.

One year of experience equivalent to the next lower level. OR, (2) Education. A bachelor'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 management, or a related degree with a minimum of 24 semester hours in health information technology/health information management (e.g., courses in medical terminology, anatomy & physiology, legal aspects of health care, and introduction to health records).

(3) Assignment. Employees at this grade level serve in developmental positions as MRTs HIT. Employees receive guidance from the supervisory MRT HIT, or designee, for more complex health record reviews.

MRTs HIT analyze health records for accuracy, completeness, timeliness, consistency, and compliance (e.g., scanned, uploaded, use of correct titles, linked to correct encounters, etc.) with HIM industry standards, policies, procedures, laws, regulations, and accreditation requirement.

They perform health record review activities to satisfy external accreditation requirements and medical center performance measures.

They create and monitor reports to ensure that deficiencies are resolved and completed appropriately.

They monitor, verify, correct, and/or upload all transcription/medical speech recognition to maintain completeness and accuracy of health records.

MRTs HIT notify clinical providers regarding incomplete health records, and assist clinical providers regarding completeness of their health record documentation.

(4) Demonstrated Knowledge, Skills, and Abilities.

In addition to the experience above, the candidate must demonstrate all of the following KSAs: (a) Ability to communicate effectively with internal and external customers.

5 (b) Ability to utilize health information technology and various office software products used in health information management positions (e.g., Microsoft Excel, electronic health records, and delinquency tracking software).

(c) Knowledge of health record documentation guidelines and industry standards. (d) Ability to manage priorities and coordinate work to complete duties within required timeframes.

(e) Ability to apply knowledge of medical terminology and human anatomy to fully understand the content of a health record. GS-0675-06: (1) Experience.

One year of experience equivalent to the next lower grade level. (2) Assignment. This is a developmental level for MRT HIT.

The MRT HIT at this level receives guidance from the supervisory MRT HIT, or designee, for more complex health records.

The MRT HIT analyzes, abstracts, maintains, extracts and compiles information from the health record, working under the review of the supervisor.

They analyze health records for accuracy, completeness, timeliness, consistency, and compliance (e.g., scanned, uploaded, use of correct titles, linked to correct encounters, etc.) with HIM industry standards, policies, procedures, laws, regulations, and accreditation requirements.

They coordinate and/or perform health record review activities to satisfy external accreditation requirements and medical center performance measures.

The MRT HIT notifies clinical providers regarding incomplete health records.

They assist clinical providers regarding completeness of their health record documentation, and the correction of health records.

They conduct reviews of incomplete records for individuals clearing the facility. They create and monitor reports to ensure that deficiencies are resolved and completed appropriately.

They monitor, verify, correct, and/or upload all transcription/medical speech recognition to maintain completeness and accuracy of health records.

MRTs HIT serve as the technical experts in health record content and documentation requirements. (3) Demonstrated Knowledge, Skills, and Abilities.

In addition to the experience above, the candidate must demonstrate all of the following KSAs: (a) Ability to navigate efficiently through the health record to locate needed information.

(b) Ability to analyze health record documentation to ensure compliance with guidelines and industry standards.

(c) Skill in investigating potential health record errors and making corrections, when appropriate.

(d) Skill in interpreting and applying health information guidelines and using 6 judgment to complete assignments. (e) Ability to follow up on incomplete health record documentation. Major Duties:

Duties: Incumbent serves as technical expert in health record content and documentation requirements.

Incumbent is responsible for performing quantitative and qualitative reviews of health record documentation.

Incumbent is responsible for ensuring that all patient care data entered in VistA and/or Computerized Patient Record System (CPRS) is accurate, timely, and completed.

Adheres to established documentation requirements as outlined by The Joint Commission regulations, Veterans Health Administration (VHA) guidelines, as well as medical-legal requirements.

Reviews records for adherence with CMS guidelines related to student, resident supervision and attending physician presence and documentation.

Compiles reports to insure provider specific and service compliance.

Maintains a control system to ensure completion of all inpatient and outpatient records in accordance with VA, The Joint Commission, CMS and other regulatory agencies standards.

Reviews health records to ensure that all records contain sufficient information to meet medical/legal requirements, to ensure continuity of patient care, and to support education and research needs.

Assists clinicians with completion of delinquent/incomplete health records. The incumbent performs the quantitative and qualitative analysis on both computer and paper-based health records.

Consults with the appropriate clinician(s) for clarification when conflicting or ambiguous information appears in the health record documentation.

Identifies health record deficiencies, tracks deficiencies and ensures that the appropriate individual completes their deficiencies.

The incumbent assists physicians with the completion of delinquent/incomplete health records and serves as the expert resource for clinical staff regarding requirements for complete documentation.

Responsible for expediting the completion of the health record when the patient is transferred for care at another medical center, for legal requests, regulatory agencies review, and reimbursement purposes.

Assesses the paper health record and electronic Computerized Patient Record System (CPRS) for completeness and notes 9eficiencies in the IRT component of VISTA.

Tracks electronic signatures and documents deficiencies and communicates these deficiencies to clinical staff for correction.

Notification can be in person, internal e-mail, telephone, or through other normal routing system.

Works independently resolving health record deficiency, issues/erroneous documents and corrective action required within CPRS and only seeks guidance of immediate supervisor and/or Clinical Application Coordinator when issues surface when no precedent or procedure has been developed.

Prepares complex weekly and monthly reports noting the status of all incomplete/delinquent records and compliance reports and submits the reports to the appropriate administrative and clinical staff.

Preforms analytical tasks associated with the resolution of "filing" errors on reports uploaded by a transcription vendor.

This includes correctly identifying the patient the report belongs too and filing/assigning it correctly. Duties includes the generation of various statistical reports to track these errors.

Makes appropriate recommendations for changes or solutions and implements appropriate recommendations for corrective action when authorized so continued filing errors do not occur.

Identifies reviews, verifies, and corrects all statistical data concerning medical transcription to maintain accuracy of medical and statistical reports.

Compares and resolves discrepancies between daily Gains and Losses Sheet, Digital System Workload Report and contract transcription logs as it relates to timeliness and accuracy of dictated reports completed by medical transcription contractor.

Reviews health records for adherence with guidelines related to resident supervision and attending physician presence.

Works with interdisciplinary staff to solve problems regarding proper health record documentation and completion.

Develops and compiles written reports trending provider specific, service, and hospital compliance reports regarding admission subsequent and discharge notes.

Obtains statistical information, applies statistical formulas, and completes statistical reports for medical center management.

Prepares weekly and monthly reports noting the status of all incomplete/delinquent health records and submits the reports to the appropriate administrative and clinical staff.

Participates in routine and focused reviews for the purpose of identifying problems and potential problems in record documentation as part of the health record review process.

Identifies and abstracts information from health records for special studies and audits both internal and external.

Work Schedule: 7:30am-4:00pm Monday-Friday Telework: Ad-Hoc Functional Statement #: 09253F, 09254F, 09255F, 09256F