Medical Records Technician (Health Information Technician)

Full Job Description

This position is located in the Health Information Management (HIM) section at the Central Arkansas Veterans Healthcare System (CAVHS).

Medical Records Technicians (MRT) Health Information Technician (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.

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.

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: Knowledge and or experience using VistA roll and scroll menus and functions Blue VistA.

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-7.

The actual grade at which an applicant may be selected for this vacancy is in the range of GS-4 to GS-7.

Physical Requirements: Physical aspects associated with work required of this assignment are typical for the occupation, see Duties section for essential job duties of the position.

May require standing, lifting, carrying, sitting, stooping, bending, puling, and pushing.

May be required to wear personal protective equipment and undergo annual TB screening or testing as conditions of employment.

Work Environment: Work is performed in an office/clinic setting with minimal risks that requires normal safety precautions; the area is adequately lighted, heated, and ventilated.

However, the work environment requires someone with the ability to handle several tasks at once in sometimes stressful situations. Major Duties:

Total Rewards of a Allied Health Professional The Medical Records Technician (MRT) Health Information Technician (HIT) serves as technical expert in health record content and documentation requirements.

The MRT is responsible for performing quantitative and qualitative reviews of health record documentation for ongoing regulatory reviews and deficiency analysis.

Incumbent is responsible for ensuring that all patient care data entered in the electronic health record (EHR) is accurate, timely, and completed.

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

Duties may include but are not limited to: Reviews health records to ensure that all records contain sufficient information to meet medico-legal requirements, to ensure continuity of patient care, and to support education and research needs.

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

Assists physicians with the completion of delinquent/incomplete health records and servers as the expert resource for clinical staff regarding requirements for complete documentation.

Prepares complex reports on a routine basis, noting the status of all incomplete/delinquent health records and submits the reports to the appropriate administrative and clinical staff.

Reviews health records for adherence with the Centers for Medicare and Medicaid Services (CMS) guidelines related to student, resident supervision and attending physician presence and documentation.

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

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

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

Utilizes EHR functionality to analyze, manage and monitor documentation and data capture deficiencies and to communicate with staff to resolve deficiencies in accordance with facility policies and performance goals.

Collects and trends data from data validation activities and audits that support continuity of patient care, budget/resource allocation, performance measurement, quality management, research, VA comparative analysis and benchmarking.

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

Work Schedule: Full-time, Monday-Friday 7:00am-4:30pm, subject to change based on the needs of the service. Recruitment Incentive (Sign-on Bonus): Not authorized.

Permanent Change of Station (Relocation Assistance): Not authorized. Pay: Competitive salary and regular salary increases.

Paid Time Off: 37-50 days of annual paid time offer per year (13-26 days of annual leave, 13 days of sick leave, 11 paid Federal holidays per year) Parental Leave: After 12 months of employment, up to 12 weeks of paid parental leave in connection with the birth, adoption, or foster care placement of a child.

Child Care Subsidy: After 60 days of employment, full time employees with a total family income below $144,000 may be eligible for a childcare subsidy up to 25% of total eligible childcare costs for eligible children up to the monthly maximum of $416.66.

Retirement: Traditional federal pension (5 years vesting) and federal 401K with up to 5% in contributions by VA Insurance: Federal health/vision/dental/term life/long-term care (many federal insurance programs can be carried into retirement) Telework: Available.

Virtual: This is not a virtual position. Functional Statement #: 598-01362F/598-01363F/598-01364F/598-01365F Permanent Change of Station (PCS): Not authorized.