Medical Records Technician (Health Information Technician)

Full Job Description

This position is located in the Health Information Management Section (HIMS) of the Health Administration Service (HAS) at the Michael E. DeBakey VA Medical Center.

Health Information Technicians (HITs) review, analyze, abstract, compile, maintain, and extract information from the health record.

They also check for completeness and accuracy of the health record and monitor and report for regulatory compliance.

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.

MRTs (HIT) must be proficient in spoken and written English as required by 38 U.S.C. § 7403(f). 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: (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).

Grade Determinations: Medical Records Technician (HIT), GS-7 (Full Performance Level) Experience. One year of experience equivalent to the next lower grade level.

AND 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 of medical terminology, Health Information Management experience, strong verbal/written communication skills, organization skills, time management skills, problem solving skills, experience with Electronic Data Capture methods, experience with Electronic Health Record, basic understanding of coding systems, and knowledge of Microsoft Office Excel.

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 GS-07.

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:

Current permanent VA employees and Federal employees from other federal agencies should apply under CBST-12924919-26-MJH.

Total Rewards of a Allied Health Professional The duties of the Medical Records Technician (Health Information Technician) may include but are not limited to: Serves as technical expert in health record content and documentation requirements.

Performs quantitative and qualitative reviews of health record documentation.

Ensures 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.

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.

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

Performs the quantitative and qualitative analysis on both computer and paper-based health records.

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.

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.

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.

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.

Work Schedule: Monday-Friday, 07:30 am - 4:00 pm (subject to change based on the needs of the facility) Recruitment Incentive (Sign-on Bonus): Not Authorized Permanent Change of Station (Relocation Assistance): Not Authorized Pay: Competitive salary and regular salary increases.

When setting pay, a higher step rate of the appropriate grade may be determined after consideration of higher or unique qualifications or special needs of the VA (Above Minimum Rate of the Grade).

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).

Selected applicants may qualify for credit toward annual leave accrual, based on prior work experience or military service experience.

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: Not Available Virtual: This is not a virtual position.

Functional Statement #: 580-00158-F Permanent Change of Station (PCS): Not Authorized