Medical Records Technician (HIT) - Full-time

Summary

This position is located in the Health Information Management (HIM) section at the Roseburg VA Healthcare System (RVAHCS). MRTs HIT perform incomplete health record analysis. They review, analyze, abstract, maintain, extract, and compile information from the health record. MRTs HIT check for accuracy, completeness, and timeliness of the health record and monitor and report for regulatory compliance.

Qualifications

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
• 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)
• Grade Determinations: In addition to the basic requirements for employment, the following criteria must be met when determining the grade of candidates
• Medical Records Technician (HIT), GS-4 (Entry Level) (1) Experience or Education
• None beyond basic requirements
• (2) Assignment
• Employees at this level serve as entry level MRTs HIT, and receive close supervision from the supervisory MRT HIT or designee
• MRTs HIT 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 accrediting bodies
• They perform health record review activities to satisfy external accreditation requirements and medical center performance measures
• They monitor, verify, correct, and upload all transcription/medical speech recognition to maintain completeness and accuracy of health records
• Medical Records Technician (HIT), GS-5 (Developmental Level 1) (1) Experience
• One year of experience equivalent to the next lower level
• OR, (2) Education
• 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 & physiology, legal aspects of health care, and introduction to health records)
• (3)Demonstrated Knowledge, Skills, and Abilities
• In addition to the experience above, the candidate must demonstrate all of the following KSAs: (a) Ability to communicate effectively with internal and external customers
• (b) Ability to utilize health information technology and various office software products used in health information management positions (e.g., Microsoft Excel, electronic health records, and delinquency tracking software)
• (c) Knowledge of health record documentation guidelines and industry standards
• (d) Ability to manage priorities and coordinate work to complete duties within required timeframes
• (e) Ability to apply knowledge of medical terminology and human anatomy to fully understand the content of a health record
• Medical Records Technician (HIT), GS-6 (1) Experience
• One year of 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) Ability to navigate efficiently through the health record to locate needed information
• (b) Ability to analyze health record documentation to ensure compliance with guidelines and industry standards
• (c) Skill in investigating potential health record errors and making corrections, when appropriate
• (d) Skill in interpreting and applying health information guidelines and using judgment to complete assignments
• (e) Ability to follow up on incomplete health record documentation
• Medical Records Technician (HIT), GS-7 (Full Performance Level) (1) Experience
• One year of experience equivalent to the next lower grade level
• (2) Demonstrated Knowledge, Skills, and Abilities
• In addition to the experience above, the candidate must demonstrate all of the following KSAs: (a) Ability to judge whether health records contain sufficient information for regulatory requirements, are acceptable as legal documents, are adequate for continuity of patient care, and support education and research needs
• (b) Ability to take appropriate actions if health record content is not adequate, accurate, timely, and/or reliable
• (c) Ability to communicate both orally and in writing with individuals or groups, to facilitate compliance with established policies and regulations
• (d) Skill in using appropriate software and computer applications to analyze and record documentation trends
• (e) Ability to apply qualitative and/or quantitative methods for assessment and improvement of health records
• (f) Ability to work independently and utilize problem-solving techniques in the accomplishment of work
• Preferred Experience: Medical Record deficiency analysis review experience preferred
• Copying and pasting position descriptions into your resume is not acceptable
• References: VA Handbook 5005/124 PART II APPENDIX G59 The full performance level of this vacancy is GS-7
• The actual grade at which an applicant may be selected for this vacancy is in the range of GS-4 to GS-7
• Physical Requirements: See VA Directive and Handbook 5019, Employee Occupational Health Service.

Duties

"This is considered the journey level for MRTs HIT.
MRTs HIT at this level 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.
The Roseburg VA Healthcare System consists of one Veterans Health Administration (VHA) facility located in Roseburg, OR, and three outpatient clinics.
RVAHCS also operates a community reintegration service center, consisting of a Homeless Program, Homeless Housing Program with the Department of Health and Human Services (HUDN ASH), Substance Abuse and Vocational Rehabilitation services.
Specialty services include Cardiology, Neurology, Infectious Diseases, Optometry, Ophthalmology, ENT, Endocrinology, Urology, Renal, Gerontology, Pulmonary, Gastroenterology, General Surgery, Dermatology and Vocational Rehabilitation.
Functions: Incumbent serves as technical expert in health record content and documentation requirements.
Incumbent is responsible for performing quantitative and qualitative reviews of health record documentation.
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 regulations, Veterans Health Administration (VHA) guidelines, as well as medical-legal requirements.
Reviews records for adherence with CMS guidelines related to student, resident supervision and attending physician presence and documentation.
Compiles reports to insure provider specific and service compliance.
Maintains a control system to ensure completion of all inpatient and outpatient records in accordance with VA, The Joint Commission, CMS and other regulatory agencies standards.
Reviews health records to ensure that all records contain sufficient information to meet medical/legal requirements, to ensure continuity of patient care, and to support education and research needs.
Assists clinicians with completion of delinquent/incomplete health records.
The incumbent performs the quantitative and qualitative analysis on both electronic and paper-based health records.
Consults with the appropriate clinician(s) for clarification when conflicting or ambiguous information appears in the health record documentation.
Identifies health record deficiencies, tracks deficiencies and ensures that the appropriate individual completes their deficiencies.
The incumbent assists physicians with the completion of delinquent/incomplete health records and serves as the expert resource for clinical staff regarding requirements for complete documentation Responsible for expediting the completion of the health record when the patient is transferred for care at another medical center, for legal requests, regulatory agencies review, and reimbursement purposes.
Assesses the electronic and paper health record for completeness and notes deficiencies in the record deficiency monitoring system.
Work Schedule: Monday - Friday 0800-1630 Telework: Available, Pending supervisor approval Virtual: This is not a virtual position.
Functional Statement #: 000000 Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized Financial Disclosure Report: Not required"