Supervisory Medical Records Technician (Health Information Technician)

Full Job Description

This position is located in the Health Information Management (HIM) section at the Black Hills Health Care System.

Medical Records Technicians (Health Information Technician) (HIT) perform incomplete health record analysis.

They review, analyze, abstract, maintain, extract, and compile information from the health record.

They check for accuracy, completeness, and timeliness of the health record and monitor and report for regulatory compliance. Creditable Experience.

Experience is only creditable if it is paid or non-paid employment directly related to the position to be filled, or in a related field, such as medical support assistants, clinic/ward clerks, health record file room/scanning technicians, medical coding, or other positions that include knowledge of the content and uses of health records.

To be creditable, the candidate's experience must have demonstrated the use of knowledge, skills, and abilities associated with current MRT HIT practice.

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.

(1) 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, (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, physiology, legal aspects of health care, and introduction to health records).

OR, (3) 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: (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.

(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 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).

c. Grandfathering Provision.

All persons employed in VHA as a MRT HIT, 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.

For 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:(1) 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.(2) Employees 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.(3) 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.

a. Physical Requirements. See VA Directive and Handbook 5019, Employee Occupational Health Service. b. English Language Proficiency.

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

Grade Determinations: Supervisory Medical Records Technician (Health Information Technician), GS-8 Experience.

One year of creditable experience at or equivalent to the next lower grade level, which includes, but not limited to: They review, analyze, abstract, maintain, extract, and compile information from the health record independently with minimal supervision.

They analyze 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.

They also coordinate and/or perform health record review activities to satisfy external accreditation requirements and medical center performance measures.

They communicate regularly with staff at various levels of the organization regarding delinquent health records, and notify individual clinical providers regarding incomplete medical records.

MRTs HIT prepare complex reports, calculate department statistics, note the status of all incomplete/delinquent records, and submit reports to the appropriate administrative and clinical staff and committees/leadership to ensure deficiencies are resolved and completed appropriately.

They serve as the expert resource for clinical staff and assist clinical providers with completion or correction of their health record documentation.

They conduct the review of incomplete records for individuals clearing the facility.

MRTs HIT coordinate the use of medical speech recognition/transcription and monitor, verify, troubleshoot, correct, and/or upload all transcription/medical speech recognition to maintain completeness and accuracy of health records.

They serve as the technical expert in health record content and documentation requirements. AND Demonstrated Knowledge, Skills, and Abilities.

In addition to the experience above, the candidate must demonstrate all of the following KSAs: (a) Knowledge of operational tasks including record completion, discharge analysis, and abstracting health records, in accordance with facility accreditation, procedures, and regulatory policies.

(b) Ability to provide expert technical guidance in health record content and documentation requirements.

(c) Skill in utilizing various software and computer applications to generate and analyze various reports. (d) Ability to coordinate and provide staff development and training.

(e) Ability to coordinate tasks and collaborate with individuals outside the work area and at higher organizational levels.

(f) Ability to provide the full range of supervisory duties, to include assignment of work, performance evaluation, selection of staff, and recommendation of awards, advancements, and disciplinary actions, when appropriate.

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 8.

The actual grade at which an applicant may be selected for this vacancy is GS 8.

Physical Requirements: You will be asked to participate in a pre-employment examination or evaluation as part of the pre-employment process for this position.

Questions about physical demands or environmental factors may be addressed at the time of evaluation or examination. Major Duties:

Total Rewards of a Allied Health Professional This position requires the incumbent to physically report for work to the Fort Meade SD VAMC.

Major duties include, but are not limited to, the following: Provide the full range of supervisory duties, which include responsibility for determining staffing needs, assignment of work, performance evaluation, selection of staff, recommendations of awards and advancements, and disciplinary actions.

Perform ongoing audits of staff for all areas of responsibility, and assign work to the staff at an appropriate quality and productivity level.

Establish goals, train employees in the accomplishment of tasks or projects, and develop written policies, procedures, and guidelines.

Serve as subject matter experts in health record content and documentation requirements.

Initiate various reports, analyze data, and work closely with clinical services to facilitate timeliness, completion, and accuracy of health record documentation.

Monitor, maintain, and create statistical data to include incomplete and delinquent records, as well as quantitative and qualitative analysis findings, to produce reports for medical center management.

Responsible for the daily operations of the HIMS HIT Unit, Scanning Unit and Operator Unit with the responsibility of resolving daily problems timely and accurately.

Responsible for basic scanning and record maintenance based on procedures outlined in applicable national and local policies.

Monitors functions to assure that the unit consistently meets the health care system demands in providing scanning services and medical records to users in a timely manner.

Provides guidance and technical direction necessary for accomplishing the work of the unit.

Provides guidance and recommendations to the Chief, HIM and Assistant, Chief HIM regarding staffing needs and shortages within the unit.

Obtains needed information on decisions from the Chief, HIM or Assistant Chief, HIM on major issues and problems that arise.

Serves as subject matter expert in health record content and documentation requirements and administrative corrections to the health record, such as correcting note titles, designating correct signer/cosigner, ensuring notes are attached to the correct episode of care, etc.

Responsible for performing quantitative and qualitative reviews of the health record documentation for ongoing regulatory reviews and deficiency analysis.

Incumbent is responsible for ensuring that all patient care data entered in the electronic health record (EHR) is accurate, timely, and completed.

Adheres to established documentation requirements as outlined by The Joint Commission (TJC) regulations, Veterans Health Administration (VHA) guidelines, as well as medico-legal requirements.

Work Schedule: Monday-Friday, 7:30am-4:00pm Recruitment Incentive (Sign-on Bonus): Not Authorized Permanent Change of Station (Relocation Assistance): Not Authorized Pay: Competitive salary and regular salary increases 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: Ad-hoc only, per Supervisor's discretion Virtual: This is not a virtual position.

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