Medical Records Technician (Release of Information)

Full Job Description

This position is located in the Health Information Management (HIM) section at the Fayetteville NC, VA Coastal Health Care System.

The MRT (ROI) reviews and processes requests for patient 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.

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~ 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).

(Transcripts Required). ~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: (Transcripts Required).

(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: In addition to the Basic Requirements above, candidates must also meet any additional requirements to include KSAs based on grade assignment below.

Medical Records Technician (ROI), GS-4 Experience or Education. None beyond basic requirements. Assignment.

Employees at this level serve in entry level MRT (ROI) position and 4 receive close supervision and support from more experienced ROI staff members.

MRTs (ROI) receive and validate authorization forms and requests for information, and prioritize requests per policies and regulations.

They use various computer applications to track and release all authorized ROI requests. They process and release health information to authorized first- and third-party requestors.

MRTs (ROI) initiate and maintain the accounting of disclosure for all records disclosed from a Privacy Act system of records.

They ensure compliance with policies, procedures, laws, and regulations governing privacy and release of information.

Reference: For more information on this qualification standard, please visit https://www.va.gov/ohrm/QualificationStandards/.

Physical Requirements: The work is sedentary, but may require walking, bending, standing, and /or carrying of light items such as files and manuals. Major Duties:

Duties include but are not limited to: Reviews and evaluates Release of Information (ROI) requests to ensure completeness, accuracy, and proper authorization prior to release.

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.

Determines what information may be released and ensures compliance with legal and regulatory requirements before disclosure.

Processes incoming ROI requests using electronic medical record systems and ROI software for logging, tracking, and documentation.

Screens requests to identify urgency and prioritizes workload according to established guidelines and timelines.

Receives and assists veterans, patients, visitors, and third parties in identifying requested information and completing required forms.

Responds to inquiries from patients, attorneys, insurance companies, government agencies, and healthcare providers regarding release of information.

Conducts electronic and paper record searches to locate, review, and verify medical information for release.

Reviews scanned and computerized health records to identify appropriate documents for copying, printing, or electronic distribution.

Processes Social Security Administration requests, including downloading records, uploading documentation, and closing requests in applicable systems.

Prepares routine written responses to requests for patient health information, including vague or incomplete inquiries.

Coordinates with clinical and administrative staff to ensure completion of medical opinion forms for VA and non-VA purposes.

Releases medical records in approved formats, including electronic media, paper copies, or other authorized methods.

Accurately enters data into ROI systems and completes required transactions related to fees, subpoenas, and legal requests.

Refers complex or problem cases to the supervisor while independently resolving routine and non-routine ROI issues.

Total Rewards of a Allied Health Professional Work Schedule: Full Time, 8:00am-4:30pm, Monday- Friday Recruitment Incentive (Sign-on Bonus): Not Authorized Permanent Change of Station (Relocation Assistance): 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) 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) Telework: Not available Virtual: This is not a virtual position.

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