MEDICAL RECORDS TECHNICIAN (ROI-LEGAL)

Full Job Description

This position is located in the Health Information Management (HIM) section of the Business Office at the Bay Pines VA Healthcare System (BPVAHCS).

The MRT (ROI) reviews and processes requests for patient protected health information (PHI).

The MRT (ROI) must possess expertise in all applicable Federal laws, rules, and regulations regarding release 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. Be a citizen of the United States.

(Non-citizens may 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 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).

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: 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.

Employees who do not meet all the basic requirements in this standard, but who met the qualifications applicable to the position at the time they were appointed to it, the following provisions apply: Such employees in an occupation that does not require a licensure/certification/ registration may be reassigned, promoted, or demoted within the occupation, but will not be promoted beyond the journey level or placed in supervisory or managerial positions.

Employees who are appointed on a temporary basis prior to the effective date of the qualification standard may not have their temporary appointment extended, or be reappointed on a temporary or permanent basis, until they fully meet the basic requirements of the standard.

Employees initially grandfathered into this occupation, who subsequently obtain additional education and/or licensure/certification/registration that meet all the basic requirements of this qualification standard, must maintain the required credentials as a condition of employment in the occupation.

GRADE REQUIREMENTS Medical Records Technician (ROI-Legal), GS-7 Experience. One full year of creditable specialized experience equivalent to the next lower grade (GS-6) level.

These are: 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. Demonstrated Knowledge, Skills, and Abilities (KSAs).

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.

(b) Ability to apply laws and regulations related to the disclosure of health information (e.g., Privacy Act, Freedom of Information Act, HIPAA, and 38 U.S.C.

§ 7332, Confidentiality of Certain Medical Records).

(c) Ability to investigate the contents of paper and electronic health records and systems that contain health information to compile the legal health record based on existing standards and requirements.

Preferred Experience: Knowledge of the laws and regulations related to the authorization and disclosure of health information as it relates to processing legal requests to attorneys and courts pertaining to Tort claims, subpoenas, depositions and court orders.

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

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

This position is located in the Health Information Management (HIM) section of the Business Office at the Bay Pines VA Healthcare System (BPVAHCS).

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

Medical Record Techs in ROI-Legal at this grade level will serve as primary points of contact and accurately process and respond timely to complex medical legal requests, including but not limited to subpoenas, depositions, testimony, and court orders for information from attorneys, courts, local law enforcement agencies or public defenders.

Serve as liaisons to Regional Counsel and US Attorney's office for trial cases. Compile the legal health record.

Extensively research and resolve conflicting or inconsistent information related to complex medical legal requests.

Duties and responsibilities of the Medical Records Technician (ROI - Legal) include, but are not limited to: 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).

Processes medical legal releases of information to attorneys and courts pertaining to Tort Feasor (Third Party Liability), Workman's Compensation, Labor and Industries and subpoenas.

Screens and follows through on all incoming telephone calls from attorneys and insurance representatives regarding legal cases and requests under the Privacy Act, referring only problem cases to the Supervisor.

Reviews and analyzes written and telephone requests to ascertain type of case to be developed. Develops and prepares cases for release to Regional Counsel and other appropriate parties.

Contacts attorneys when necessary to obtain additional information to develop the case.

Maintains files for all Privacy Act requests and subpoena cases for all cases being developed, processed or complete. Compiles tort cases for the Regional Office.

This requires extensive investigations to track down x-rays and health records to compile a complete health record.

Contacts all VA's to have them make a CD of all of the photocopied/printed/written to electronic media information, including digital x-rays.

All paper health records are arranged in date order, numbered and several exact copies made for the Regional Office.

All computer health records are downloaded to a CD including documents in VistA Imaging. For cases going to trial, this may include additional updates and coordination with the US Attorney's Office.

Interviews veterans and insurance agents requesting information for Third Party Liability, Workman's Compensation, and Privacy Act cases for referral to Medical Cost Recovery and/or the Regional Counsel's Office.

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.

Reviews 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.

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.

Work Schedule: Monday - Friday; 08:00am - 4:30pm Telework: Not Available Virtual: This is not a virtual position.

Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized PCS Appraised Value Offer (AVO): Not Authorize