Medical Records Technician (HIT)

Full Job Description

This position is in the Health Information Management (HIM) section at the John D Dingell VA Medical Center.

Medical Records Technician (Health Information Technician) 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.

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: 1 year of creditable experience that indicates knowledge of medical terminology, anatomy, physiology, and a general understanding of health records.

6 months of the required 1 year of creditable experience must have provided the knowledge, skills, and abilities (KSAs) needed to perform HRT HIT work; OR, Education: Associate's degree from an accredited college/university recognized by the U.S.

Department of Education, w/ a major field of study in health information technology/management, or related degree with a min.

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 that qualify for meeting the basic requirements.

The following educational/training substitutions are appropriate for combining education and creditable experience: 6 months of creditable experience that indicates knowledge of medical terminology, privacy and release of information, the health record, and 1 year above high school, w/ a min.

of 6 semester hours of health information technology/health information management.

6 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 my 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 6 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: GS-04 Experience/Education: None beyond the basic requirement. GS-05 Experience/Education:Experience.

1 year of creditable experience equivalent to the next lower grade level which may include but is not limited to: analyze health records for accuracy, completeness, timeliness, consistency, and compliance w/ 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.

Successful completion of a bachelor's degree from an accredited college or university recognized by the U.S.

Department of Education, w/ a major field of study in health information management, or a related degree w/ a minimum of 24 semester hours in health information management or technology (e.g.

courses in medical terminology, anatomy & physiology, legal aspects of health care, and introduction to health records). Demonstrated KSAs.

In addition to the education/experience above, must demonstrate all of the following: Ability to communicate effectively w/ internal/external customers Ability to utilize health information technology and various office software products used in health information management positions Knowledge of health record documentation guidelines and industry standards Ability to manage priorities and coordinate work to complete duties w/in required time frames Ability to knowledge of medical terminology and human anatomy to fully understand the content of a health record GS-06 Experience.

1 year of creditable experience equivalent to the next lower grade level.

This experience may include but is not limited to: Analyze health records for accuracy, completeness, timeliness, consistency, and compliance w/ 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.

Monitory, 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. Demonstrated KSAs.

In addition to the education/experience above, must demonstrate all of the following: 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-07 Experience.

1 year of creditable experience equivalent to the next lower grade level which may include but is not limited to: Analyze, abstract, maintain, extract and compile information from the health record, working under the review of the supervisor.

Analyze health records for accuracy, completeness, timeliness, consistency, and compliance w/ 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.

Monitor, verify, correct, and/or upload all transcription/medical speech recognition to maintain completeness and accuracy of health records. Demonstrated KSA's.

In addition to the education/experience above, must demonstrate all of the following: 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 w/ 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 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. Continued in Education section below... Major Duties:

Total Rewards of a Allied Health Professional Major duties include: Review health records to ensure all records contain enough information to meet medical/legal requirements, to ensure continuity of patient care, and to support education and research needs.

Analysis of PTF procedures track and monitor PTF errors and transmit corrected data timely.

Set work priorities and meet deadlines for closing PTF records, preparing delinquent records, preparing excel spreadsheet and completing incomplete reports.

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.

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

The incumbent sends physicians with the incomplete/delinquent health records and serves as the expert resource for clinical staff regarding requirements for complete documentation.

Assesses the paper health record and electronic Computerized Patient Record System (CPRS) for completeness and notes deficiencies in the (IRT, Nuance, VISTA, VISTA Imaging).

Tracks 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 record deficiency issues/erroneous documents and corrective action required within CPRS and seeks guidance of immediate supervisor and/or Clinical Application Coordinator when issues surface when no precedent or procedure has been developed.

Review and validate the Edit Analysis Lists (EALs) and the Dispositions in the PTF Master File

The EALs are sent in a VistA Mailman message in response to PTF or census transmissions that have data errors. The 419 and census reports are based in Austin at the AITC and require special access.

Prepares complex weekly and monthly reports noting the status of all incomplete/delinquent records and compliance reports and submits the reports to the Chief of HIMS, BP Leadership and clinical staff.

Performs analytical tasks associated with the resolution of "filing" errors on reports uploaded onto spreadsheet.

This includes correctly identifying the coder on the report and providing this information to be corrected. Duties may also include the generation of various statistical report to track these errors.

Makes appropriate recommendations for changes or solutions and facilitate corrective action when applicable. Identifies reviews, verifies, and corrects all statistical data concerning MR post reports.

Develops and compiles written reports trending provider specific, service, and hospital compliance reports regarding admission subsequent and discharge notes.

Identifies and abstracts information from health records for special studies and audits both internal and external. Work Schedule: Monday-Friday; 8:00am to 4:30pm EST.

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

Functional Statement #: 91207-0, 91208-0, 91209-0, 91210-0 Relocation/Recruitment Incentives: Not authorized Permanent Change of Station (PCS): 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)