Medical Records Technician (Health Information Technician)

Full Job Description

Position is located in the Health Information Management section at the EPVAHCS. Performs incomplete health record analysis & processes medical record corrections.

Reviews, analyzes, abstracts, maintains, extracts, corrects & compiles information from the health record.

Checks for accuracy, completeness & timeliness of the medical record & monitors and reports for regulatory compliance.

Incumbent is a technical expert in medical record content & documentation requirements.

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: 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, 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, 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: 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.

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.

Physical Requirements: See VA Directive and Handbook 5019, Employee Occupational Health Service.

English Language Proficiency: MRTs HIT 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).

Grade Determinations: Medical Records Technician (HIT), GS-4 (Entry Level) Experience or Education.

None beyond basic requirements Medical Records Technician (HIT), GS-5 (Developmental Level 1) Experience. One year of experience equivalent to the next lower level. OR, 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).

Demonstrated Knowledge, Skills, and Abilities.

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

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).

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

Ability to apply knowledge of medical terminology and human anatomy to fully understand the content of a health record. Medical Records Technician (HIT), GS-6 Experience.

One year of experience equivalent to the next lower grade level Demonstrated Knowledge, Skills, and Abilities.

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

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

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

Skill in interpreting and applying health information guidelines and using judgment to complete assignments. Ability to follow up on incomplete health record documentation.

Medical Records Technician (HIT), GS-7 (Full Performance Level) Experience. One year of experience equivalent to the next lower grade level. Demonstrated Knowledge, Skills, and Abilities.

In addition to the experience above, the candidate must demonstrate all of the following KSAs: Ability to judge whether health 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.

Ability to take appropriate actions if health record content is not adequate, accurate, timely, and/or reliable.

Ability to communicate both orally and in writing with individuals or groups, to facilitate compliance with established policies and regulations.

Skill in using appropriate software and computer applications to analyze and record documentation trends.

Ability to apply qualitative and/or quantitative methods for assessment and improvement of health records.

Ability to work independently and utilize problem-solving techniques in the accomplishment of work. Preferred Experience: Three years of experience working with the electronic health record.

Experience compiling reports for presentation.

Experience identifying and investigating the appropriate type of medical record correction necessary for the type of medical record error made to ensure completeness and accuracy of medical record documentation.

Ability to communicate both orally and in writing with individuals or groups, to facilitate compliance with established policies and regulations.

Experience or Knowledge of identification Copy Paste criteria within medical record documentation.

Reference: For more information on this qualification standard, please visit https://www.va.gov/ohrm/QualificationStandards/. The full performance level of this vacancy is GS-07.

The actual grade at which an applicant may be selected for this vacancy is in the range of GS-04 to GS-07. Physical Requirements: The work is sedentary.

Some work may require movement between offices, hospitals, warehouses, and similar areas for meetings and to conduct work.

Work may also require walking/standing, in conjunctions with travel to and attendance at meetings and/or conferences away from the work site.

Incumbent may carry and lift light items weighing less than 15 pounds. Major Duties:

Duties include, but are not limited to: Serving as technical expert in health record content and documentation requirements Responsible for performing quantitative and qualitative reviews of health record documentation Responsible for ensuring that all patient care data entered in VistA and/or Computerized Patient Record System (CPRS) is accurate, timely, and completed.

Adhering to established documentation requirements as outlined by The Joint Commission regulations, Veterans Health Administration (VHA) guidelines, as well as medical-legal requirements Reviewing records for adherence with CMS guidelines related to student, resident supervision and attending physician presence and documentation Complying reports to insure provider specific and service compliance Maintaining 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 Reviewing 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.

Identifying and investigating the appropriate type of medical record correction necessary for the type of medical record error made to ensure overall completeness and accuracy of medical record documentation that supports services rendered to patients, appropriate workload, and resource allocations.

Assisting clinicians with completion of incomplete/delinquent health records Performing quantitative and qualitative analysis on both computer and paper-based health records.

Through extensive interaction and collaboration with key Health System Specialists, the MRT-HIT makes corrections that are vital to the medical record's integrity Consulting with the appropriate clinician(s) for clarification when conflicting or ambiguous information appears in the health record documentation Reviewing health records for adherence with guidelines related to resident supervision and attending physician presence Working with interdisciplinary staff to solve problems regarding proper health record documentation and completion Developing and compiling written reports trending provider specific, service, and hospital compliance reports regarding admission subsequent and discharge notes Obtaining statistical information, applying statistical formulas and completing statistical reports for medical center management Preparing weekly and monthly reports noting the status of all incomplete/delinquent health records and submitting the reports to the appropriate administrative and clinical staff Participating 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 Identifying and abstracting information from health records for special studies and audits both internal and external Work Schedule: Monday thru Friday 8:00 a.m.

to 4:45 p.m. Telework: Available. Ad-hoc Virtual: This is not a virtual position.

Functional Statement #: 000000 Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized