Medical Records Technician (Heath Information Technicians)

Full Job Description

This position is located in the Health Information Management (HIM) section at the at the VA Wilmington Healthcare System.

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.

Experience & 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.

Grade Determinations:GS-4 MRT (HIT), (Entry Level) Experience or Education. None beyond basic requirements. GS-5 MRT (HIT), (Developmental Level 1) Experience.

One year of experience equivalent to the next lower level.

Qualifying experience includes: 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; perform health record review activities to satisfy external accreditation requirements and medical center performance measures; monitor, verify, correct, and upload all transcription/medical speech recognition to maintain completeness and accuracy of health records.

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).

AND In addition to experience above, candidate must demonstrate 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 MRT (HIT) Experience.

One year of experience equivalent to the next lower grade level.

Qualifying experience includes: 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; perform health record review activities to satisfy external accreditation requirements and medical center performance measures; create and monitor reports to ensure that deficiencies are resolved and completed appropriately; monitor, verify, correct, and/or upload all transcription/medical speech recognition to maintain completeness and accuracy of health records; notify clinical providers regarding incomplete health records, and assist clinical providers regarding completeness of their health record documentation.

AND In addition to experience above, candidate must demonstrate 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 MRT (HIT), (Full Performance Level) Experience. One year of experience equivalent to the next lower grade level.

Qualifying experience includes: analyzes, abstracts, maintains, extracts and compiles information from the health record, working under the review of the supervisor; 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; coordinate and/or perform health record review activities to satisfy external accreditation requirements and medical center performance measures; notifies clinical providers regarding incomplete health records; assist clinical providers regarding completeness of their health record documentation, and the correction of health records; conduct reviews of incomplete records for individuals clearing the facility; create and monitor reports to ensure that deficiencies are resolved and completed appropriately; monitor, verify, correct, and/or upload all transcription/medical speech recognition to maintain completeness and accuracy of health records; serve as the technical experts in health record content and documentation requirements.

AND In addition to experience above, candidate must demonstrate 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. Major Duties:

Major duties include but not limited to: Responsible for abstraction of clinical information for ongoing regulatory reviews and advising the clinical treatment team on issues related to record completion and documentation requirements.

Contacts physicians and other ancillary service personnel regarding dictation and/or signatures.

Monitors delinquent dictation list for follow-up purposes on necessary documents (i.e., operation reports, discharge summaries, etc.) that are needed for completion of health records.

Notifies appropriate physician and other personnel of the status of dictation.

Utilizes basic knowledge of medical terminology, anatomy and physiology, and coding to research and collect information for various medical studies and research projects utilizing the Patient Treatment File (PTF) and PTF microfiche.

Serves 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.

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.

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.

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.

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

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

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, 8:00am - 4:30pm Telework: Not Available Virtual: This is not a virtual position. Functional Statement #: Medical Records Technician (HIT) - GS-0620-04T7 Appendix G59