Medical Records Technician (Release of Information)

Full Job Description

The MRT (ROI) works within Health Administration Service (HAS), Health Information Management Services (HIMS), and reviews, indexes, and processes requests for Protected Health Information (PHI).

The MRT (ROI) also provides direct customer service to the Veteran or third party, by providing copies of the Veteran's PHI, when a signed, written request is received, or upon the Veteran's valid authorization to a third party.

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.

MRTs (ROI) must be proficient in spoken and written English, as required by 38 U.S.C. § 7403(f). Experience and Education (1) Experience.

One year of creditable experience that indicates knowledge of medical terminology and 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 (ROI) 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 and 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 experience and 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 courses.

(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 Armed Forces or the U.S.

Maritime Service under close medical and professional supervision.

The training program may be substituted on a month-for-month basis for up to six months of experience provided the training program included courses in anatomy and 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 (ROI), GS-4 Experience or Education. None beyond basic requirements. Medical Records Technician (ROI), GS-5 Experience.

One year of creditable experience equivalent to the next lower grade level; OR, Education.

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).

Demonstrated Knowledge, Skills, and Abilities.

In addition to the experience above, the candidate must demonstrate all of the following KSAs: (a) Ability to utilize health information technology and various office software products utilized in MRT (ROI) positions (e.g., the electronic health record, release of information systems, etc.).

(b) Knowledge of health record documentation guidelines and processes for disclosing protected health information.

(c) Ability to manage priorities and coordinate work in order to complete duties within required timeframes, and the ability to follow-up on pending issues.

(d) Knowledge of policies, procedures, laws, and regulations governing privacy and release of information.

(e) Ability to communicate with individuals from various backgrounds to obtain the desired effect or gaining information by establishing rapport. Medical Records Technician (ROI), GS-6 Experience.

One year of creditable 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: (a) Knowledge of the laws and regulations related to the authorization and disclosure of health information (e.g., Privacy Act, Freedom of Information Act, Health Insurance Portability and Accountability Act (HIPAA), and 38 U.S.C.

§ 7332, Confidentiality of Certain Medical Records).

(b) Ability to apply health record documentation guidelines and processes to navigate efficiently through the paper and/or electronic health record to locate, assemble, and disclose protected health information.

(c) Ability to apply policies, procedures, laws, and regulations governing privacy and release of information to process requests for release of information.

(d) Ability to research and solve difficult questions related to release of health information in an accurate and timely manner.

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-06.

The actual grade at which an applicant may be selected for this vacancy is in the range of GS-04 to GS-06.

Physical Requirements: See VA Directive and Handbook 5019, Employee Occupational Health Service. Major Duties:

At the full performance level (GS-06), you will serve as a Medical Records Technician (Release of Information) responsible for applying, interpreting, and analyzing laws and regulations related to the disclosure of health information.

Your duties will include, but are not limited to: Evaluate the adequacy of each completed authorization form.

Screen each request for information to determine urgency and assure that most urgent requests are completed first using established priority systems.

Professionally greet veterans/visitors and assist them in determining the exact nature of the request and whether the information requested can be released.

Apply public laws, rules, regulations and exclusions governing confidentiality of the medical record, including the Privacy Act, Freedom of Information Act (FOIA) and 38 U.S.C.

7332 governing the release of records containing information regarding the treatment of or referral for drug and/or alcohol abuse, Sickle Cell Anemia, and infection with Human Immunodeficiency Virus (HIV).

Process all incoming requests to the facility for Release of Information (ROI) along with information required by the VA Regional Office through the Automated Medical Information Exchange (AMIE), referring only problem cases to the Supervisor.

Evaluate the validity of each request.

Determine which information is to be released in compliance with existing laws (Privacy Act of 1974, FOIA, and Health Insurance Portability and Accountability Act).

Ensure that proper authorization exists before release is made. Process the request to the requesting agency or individual.

Input all requests into the ROI computer package for logging and tracking of these requests. Receive and direct callers and visitors.

Receive and/or give out forms and assist visitors and/or callers with the completion of forms or documents. Respond to questions from patients concerning services.

Provide advisory and technical assistance to patients, administrative staff, and professional staff regarding release of information.

Search records or files to compose responses, including electronic searches to retrieve and summarize hard-to-locate data. Locate materials that would verify information given.

Review paper and computerized health records (i.e., scanned notes, reports, special tests, etc.) to identify material to be photocopied/printed/written to electronic media and released.

Compose responses to routine requests for release of patient information.

Select and compile information from health records and prepare correspondence, typically using standard form or standard formats for letters.

Ensure the information released is limited to what is specifically authorized and to the person or agency designated to receive it.

Compose detailed explanations in response to correspondence received, arranging information into logical sequence and appropriate format and choosing appropriate words and expressions to convey the desired tone.

Determine extent and tone of replies independently. Resolve conflicting or inconsistent information found on initial requests.

This involves dealing with patients and/or third parties to resolve discrepancies, sorting out errors and reconstructing past transactions, cases or events, or finding alternative sources of information.

Reply to vague, incomplete, or ambiguous inquires by independently recognizing issues, topics or problems.

Find alternative sources of information on which to base a reply when correspondent has provided sketchy or inaccurate information.

Process Social Security requests for health information using ROI software. Download VistA Imaging documents and ROI software documents onto a secure Network Drive.

Access the secured Social Security Web page and upload the documents to the Web portal.

Transfer the confirmation codes to the ROI software package and close the requests in both the ROI and Social Security packages.

Work Schedule: Monday - Friday, 8:00AM - 4:30pm Telework: This position may be authorized only ad hoc telework, at managements discretion. Virtual: This is not a virtual position.

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