Medical Records Technician (HIT)

Full Job Description

This position is in the Health Information Management (HIM) Service at the VA St. Louis Health Care System (VASTLHCS) in St. Louis, Missouri. MRTs 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-04: Experience or Education. None beyond basic requirements. Medical Records Technician (HIT), GS-05: Experience.

One year of creditable experience equivalent to the GS-04 level; OR Education. The successful completion of 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 and physiology, legal aspects of health care, and introduction to health records); AND Demonstrate all of the following Knowledge, Skills and Abilities (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-06: Experience: One year of creditable experience equivalent to GS-05 level; AND Demonstrate all of the following Knowledge, Skills and Abilities (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-07: Experience: one year of creditable experience equivalent to GS-06 level; AND Demonstrate all of the following Knowledge, Skills and Abilities (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 VISTA and CPRS 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 in the range of GS-04 to GS-07.

Physical Requirements: Use of Computerized Systems. Major Duties:

The Medical Records Technician (Health Information Technician) HIT analyzes, abstracts, maintains, extracts, and compiles information from the health record.

They analyzed 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.

Major Duties include, but are not limited to the following: Coordinate and/or perform quantitative and qualitative health record reviews Notify clinical providers regarding incomplete health records Assist clinical providers Conduct other reviews as needed Create and monitor reports Ensure that deficiencies are resolved and completed appropriately Monitor, verify, correct, and/or upload any medical speech recognition documentation Maintain the completeness and accuracy of health records Serve as the technical expert in health record content and documentation requirements Utilize Computerized Patient Record System (CPRS) and/or VistA to enter patient care data Adhere to established documentation requirements Ensure that records meet medical/legal requirements Consult with Clinicians Utilize Incomplete Record Tracking (IRT) and SharePoint to track deficiencies Prepare weekly and monthly reports Conduct studies and audits Assist with scanning documentation Assist with other tasks assigned by supervisor Work Schedule: Monday - Friday; 8-4:30 pm CST - subject to change Recruitment Incentive (Sign-on Bonus): Not Authorized Permanent Change of Station (Relocation Assistance): Not Authorized Telework: Not Available Virtual: This is not a virtual position.

Functional Statement #: 000000 Permanent Change of Station (PCS): Not Authorized