Medical Records Technician (Release of Information)

US Government, Department of Veterans Affairs

This position is located in the Health Information Management (HIM) section of the Business Office at the Lee County, Cape Coral VA facility. The Medical Records Technician (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.

 

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Job Grade: 4
Total Openings:

Duties:

Medical Records Technician (Release of Information) at this level apply, interpret, and analyze laws and regulations related to the disclosure of health information. MRTs (ROI) are responsible for educating requestors on requirements for submitting requests for health information. They receive and validate authorization forms and requests for information and prioritize requests according to policies and regulations. They use various computer applications to track and release all authorized release of information requests. Duties and responsibilities of the Medical Records Technician (Release of Information) include, but are not limited to: Responsible for evaluating the adequacy of each completed authorization form. Screens each request for information to determine urgency and assures that most urgent requests are completed fist using established priority systems. Applies public laws, rules, regulations and exclusions governing confidentiality of the medical record. Process 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), referring only problem cases to the Supervisor. 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). 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. Provides advisory and technical assistance to patients, administrative staff and professional staff regarding release of information. Searches records or files to compose responses, including electronic searches to retrieve and summarize hard-to-locate data. 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. Selects and compiles information from health records and prepares correspondence, typically using standard form or standard formats for letters. Composes detailed explanations in response to correspondence received, arranging information into logical sequence and appropriate format and choosing appropriate words and expressions to convey the desired tone. Resolves conflicting or inconsistent information found on initial requests, which involves dealing with patients and/or third parties to resolve discrepancies, sorting out errors and reconstructing past transactions, cases or events, or finding alternative sources of information. Completes and processes routine releases of information to other VA and Federal Agencies and when requested, to patients and their families, insurance representatives, physicians, hospitals, and city and state health agencies according to VA directives. Work Schedule: Full-time, Monday through Friday, 8:00 am to 4:30 pm
Telework: Not Available
Virtual: This is not a virtual position.
Relocation/Recruitment Incentives: Not Authorized
Permanent Change of Station (PCS): Not Authorized
Financial Disclosure Report: Not required

Qualifications:

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. 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: 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. TRANSCRIPTS REQUIRED 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. TRANSCRIPTS REQUIRED 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 DETERMINATION Medical Records Technician (ROI), GS-4: Nothing beyond the basic requirements listed above. Medical Records Technician (ROI), GS-5: Experience. One year of creditable experience equivalent to the next lower grade level (GS-04). OR, Education. Successful completion of 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 and physiology, legal aspects of health care, and introduction to health records). AND Demonstrated Knowledge, Skills, and Abilities. In addition to the experience above, the candidate must demonstrate all of the following KSAs: Ability to utilize health information technology and various office software products utilized in MRT (ROI) positions (e.g., the electronic health record, release of information systems, etc.). Knowledge of health record documentation guidelines and processes for disclosing protected health information. Ability to manage priorities and coordinate work in order to complete duties within required timeframes, and the ability to follow-up on pending issues. Knowledge of policies, procedures, laws, and regulations governing privacy and release of information. Ability to communicate with individuals from various backgrounds to obtain the desired effect or gaining information by establishing rapport. Medical Records Technician (ROI), GS-6: Experience. One year of creditable experience equivalent to the next lower grade level (GS-05). Knowledge, skills and abilities at the GS-05 are listed above. AND Demonstrated Knowledge, Skills, and Abilities. In addition to the experience above, the candidate must demonstrate all of the following KSAs: 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. References: VA Handbook 5005/123, PART II, APPENDIX G58 The full performance level of this vacancy is GS-06. The actual grade at which an applicant may be selected for this vacancy is in the range of GS-04 to GS-06. Physical Requirements: The work is sedentary in nature and takes place in an office environment. It requires standing, walking, bending, twisting, carrying light items under 15 pounds, and both hands. See VA Directive and Handbook 5019, Employee Occupational Health Service.

Job Requirements:

You must be a U.S. Citizen to apply for this job. All applicants tentatively selected for VA employment in a testing designated position are subject to urinalysis to screen for illegal drug use prior to appointment. Applicants who refuse to be tested will be denied employment with VA. 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.

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