Medical Records Technician (Health Information Technician)

Full Job Description

This position is in the Health Information Management (HIM) Service at the Syracuse VAMC.

Medical Records Technician's (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. English Language Proficiency.

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.

(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).

Grandfathering Provision.

All persons employed in VHA as a MRT HIT, 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.

For 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 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.

Grade Determinations: GS-4. None beyond basic requirements. GS-5. 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. 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. GS-7. 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. References: VA Handbook 5005, Appendix G59.

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: Work is sedentary but also demands standing, walking, bending, twisting, and carrying light items. Major Duties:

Major Duties Include but are not limited to: 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. 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 tracks documentation deficiencies.

Monitors 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.

Performs analytical tasks associated with the resolution of errors on documentation entered in CPRS.

This includes correctly identifying the patient the report belongs too and filing/assigning it correctly.

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

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

Compares and resolves discrepancies between daily Gains and Losses Sheet and documentation as it relates to timeliness and accuracy of the health record.

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.

Work Schedule: Monday - Friday 7:00 am - 3:30 pm OR 7:30 am - 4:00 pm Telework: Ad-hoc Virtual: This is not a virtual position. Functional Statement #: 21X84A