This position is in Health Information Management (HIMS) Section within Benefits and Data Management Service at the VA Northern California Health Care System. Medical Records Technician, Health Information Technician’s (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.

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Job Grade: 4
Total Openings: 1

Duties:

Major duties include but are not limited to the following: 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 medical record is monitored to be accurate, timely, and complete. 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 ensure 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 utilizes technical ability to maneuver within electronic medical records on multiple platforms to perform the quantitative and qualitative analysis. 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. Utilizes in-depth computer skills and data analysis abilities to prepare complex weekly and monthly reports noting the status of all incomplete/delinquent records and compliance reports and submits the reports to the appropriate administrative and clinical staff. Preforms analytical tasks associated with the resolution of “filing” errors on reports uploaded by a transcription vendor. This includes correctly identifying the patient the report belongs too and filing/assigning it correctly. Duties includes the generation of various statistical reports to track these errors. Reviews health records for adherence with guidelines related to resident supervision and attending physician presence. Assists with all quality monitoring and improvement requirements regarding medical records and documentation outcomes from regulatory agencies such as the Office of the Inspector General and The Joint Commission. Reviews health records for adherence with guidelines related to resident supervision and attending physician presence. Provides administrative support to designated medical record and documentation related committees. Responsible for registering, setting up, and training providers to utilize Dragon speech recognition software. Provide customer service for Dragon software issues, questions, and any related provider needs. Work Schedule: M-F 8:00 am – 4:30 pm
Telework: Available (Pending manager determination)
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

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/Education: Applicants must meet one of the following education and/or experience requirements below. 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 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 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: Medical Records Technician (HIT), GS-4 (Entry Level) Experience or Education. None beyond basic requirements. Medical Records Technician (HIT), GS-5 (Developmental Level 1) *This is the target grade of this announcement* Experience. One year of experience equivalent to the next lower level. OR 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). GS-05 Knowledge, Skills, and Abilities Ability to communicate effectively with internal and external customers. 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). Ability to manage priorities and coordinate work to complete duties within required timeframes. 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:Experience. One year of experience equivalent to the next lower grade level.GS-06 Knowledge, Skills, and Abilities Ability to navigate efficiently through the health record to locate needed information. Ability to analyze health record documentation to ensure compliance with guidelines and industry standards. Skill in investigating potential health record errors and making corrections, when appropriate. Skill in interpreting and applying health information guidelines and using judgment to complete assignments. Ability to follow up on incomplete health record documentation. Medical Records Technician (HIT), GS-7 (Full Performance Level)Experience. One year of experience equivalent to the next lower grade level.GS-07 Knowledge, Skills, and Abilities: 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. Ability to take appropriate actions if health record content is not adequate, accurate, timely, and/or reliable. Ability to communicate both orally and in writing with individuals or groups, to facilitate compliance with established policies and regulations. Skill in using appropriate software and computer applications to analyze and record documentation trends. Ability to apply qualitative and/or quantitative methods for assessment and improvement of health records. Ability to work independently and utilize problem-solving techniques in the accomplishment of work. References: VA Handbook 5005, Part II, Appendix G59 Physical Requirements: Requires standing for short periods. Requires frequent movement within work areas, regular and recurring bending, stopping, sitting, and stretching. The work requires lifting/carrying of light items. Office environment.

Job Requirements:

You must be a U.S. Citizen to apply for this job. Selective Service Registration is required for males born after 12/31/1959. Must be proficient in written and spoken English. You may be required to serve a probationary period. Subject to background/security investigation. Selected applicants will be required to complete an online onboarding process. Must pass pre-employment physical examination. Participation in the seasonal influenza vaccination program is a requirement for all Department of Veterans Affairs Health Care Personnel (HCP). Participation in the Coronavirus Disease 2019 (COVID-19) vaccination program is a requirement for all Veterans Health Administration Health Care Personnel (HCP) – See “Additional Information” below for details.