Medical Records Technician (Release Of Information)

Full Job Description

This position is located at the Toledo Clinic in Toledo, Ohio under the Health Information Management (HIM) section at the Ann Arbor VA Medical Center.

The Release of Information (ROI) technicians disclose health information in accordance with all laws and regulations governing authorization and disclosure of health information.

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: Citizenship: Must be a citizen of the United States. Non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy.

English Language Proficiency. Medical Records Technicians (ROI) must be proficient in spoken and written English, as required by 38 U.S.C. § 7403(f).

A) Experience: One year of experience that indicates knowledge of medical terminology and general understanding of the health records.

Six months of the required one year of creditable experience must have provided the knowledge, skill, and abilities (KSA's) needed to perform MRT (ROI) work.

OR B) Education: An associates 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 C) Experience/Education Combination: Equivalent combinations of experience and education are qualifying towards meeting basic experience requirements.

The following experience and education/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 courses.

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.

Grandfathering Provision.

All persons employed in VHA as a MRT (ROI) on the effective date of this qualification standard are considered to have met all qualification requirements for the grade held, including positive education and licensure/certification/registration that are part of the basic requirements of the occupation.

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: 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.).

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

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

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

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: 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).

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.

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

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/. VA Handbook 5005/123 PART II APPENDIX G58.

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: The duties of this job are primarily sedentary in nature. The work requires long periods of sitting and viewing documentation on a computer monitor.

The employee must occasionally lift and/or move up to 50lbs of documentation that arrives from the mail department.

Patient mental status and physical habitus will require the incumbent to be able to assist patients complete release of information and other service-related forms and well as assist customers understand the processes, policies, and regulations that govern our services.

Specific vision abilities required by this job function include but are not limited are close vision, distance vision, peripheral vision, depth perception, and ability to adjust focus. Major Duties:

GS-4 Summary of Duties The incumbent processes 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).

Evaluates validity of each request.

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

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

Inputs all requests into the ROI computer package for logging and tracking of these requests. Receives and directs callers and visitors.

Receives and/or gives out forms, and assists visitors and/or callers with the completion of forms or documents. Responds to questions from patients concerning services.

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

Inquiries vary widely and information given requires explanation of office functions, describing specific requirements, providing basic instructions, or a similar degree of detail.

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

Employee composes responses to routine requests for release of patient information.

Selects and compiles information from health records and prepares correspondence, typically using standard form or standard formats for letters.

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

GS-5 Summary of Duties The duties in this position are primarily advisory and technical in nature. Incumbent is responsible for evaluating the adequacy of each completed authorization form.

Screens each request for information to determine urgency and assures that most urgent requests are completed fist using established priority systems.

Personally, greets veterans /visitor, assists them in determining the exact nature of the request and whether the information requested can be released.

Applies public laws, rules, regulations and exclusions governing confidentiality of the medical record, including the Privacy Act, Freedom of Information Act 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).

The incumbent processes 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).

Evaluates validity of each request.

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

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

Inputs all requests into the ROI computer package for logging and tracking of these requests. Receives and directs callers and visitors.

Receives and/or gives out forms, and assists visitors and/or callers with the completion of forms or documents. Responds to questions from patients concerning services.

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

Inquiries vary widely and information given requires explanation of office functions, describing specific requirements, providing basic instructions, or a similar degree of detail.

GS-6 Summary of Duties The duties in this position are primarily advisory and technical in nature. Incumbent is responsible for evaluating the adequacy of each completed authorization form.

Screens each request for information to determine urgency and assures that most urgent requests are completed fist using established priority systems.

Personally, greets veterans/visitors and assists them in determining the exact nature of the request and whether the information requested can be released.

Applies public laws, rules, regulations and exclusions governing confidentiality of the medical record, including the Privacy Act, Freedom of Information Act 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).

Work Schedule: Monday - Friday 8am to 4:30pm Telework: Not Available Virtual: This is not a virtual position.

Functional Statement #: GS-4 FS# 92509-A / GS-5 FS# 92510-A / GS-6FS# 92511-A Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized