MEDICAL RECORDS TECHNICIAN (HEALTH INFORMATION TECHNICIAN)
Duties include, but are not limited to:
Performs quantitative and qualitative reviews of health record documentation. Ensures that all patient care data entered in VISTA and/or Computerized Patient Record System (CPRS) 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. Identify health record deficiencies, tracks deficiencies and ensures that the appropriate individual completes their deficiencies. Expedites 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. Tracks electronic signatures and documents deficiencies and communicates these deficiencies to clinical staff for correction. Prepares 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. Performs analytical tasks associated with the resolution of filing errors on reports uploaded by a transcription vendor. Identifies reviews, verifies, and corrects all statistical data concerning medical transcription to maintain accuracy of medical and statistical reports. Works with interdisciplinary staff to solve problems regarding proper health record documentation and completion. Develops and compiles written reports trending provider specific, service, and hospital compliance reports regarding admission subsequent and discharge notes. The duties listed above are for full performance level (GS-7), developmental grade level duties will be of lower complexity and greater supervision. Work Schedule:
8:
00 am - 4:
30 pm, Monday - Friday Financial Disclosure Report:
Not required 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. AND English Language Proficiency:
MRTs HIT must be proficient in spoken and written English, as required by 38 U.S.C. 7403(f). AND
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:
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. OR Experience/Education Combination:
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). 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):
Experience or Education:
One year of experience equivalent to the next lower level (GS-4). OR 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). AND Demonstrated Knowledge, Skills, and Abilities (KSA's):
(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:
Experience:
One year of experience equivalent to the next lower grade level (GS-5). AND Demonstrated KSA's:
(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):
Experience:
One year of experience equivalent to the next lower grade level (GS-6). AND Demonstrated KSA's:
(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. References:
VA Handbook 5005/124, Part II, Appendix G59, December 10, 2019 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:
Moderate lifting (15-44 lbs); use of fingers; use of both hands; walking, standing, repeated bending for 1 hour; ability to see a computer screen; hearing aids are permitted. Environmental factors include working alone or working closely with others.
Estimated Salary: $20 to $28 per hour based on qualifications.
Performs quantitative and qualitative reviews of health record documentation. Ensures that all patient care data entered in VISTA and/or Computerized Patient Record System (CPRS) 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. Identify health record deficiencies, tracks deficiencies and ensures that the appropriate individual completes their deficiencies. Expedites 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. Tracks electronic signatures and documents deficiencies and communicates these deficiencies to clinical staff for correction. Prepares 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. Performs analytical tasks associated with the resolution of filing errors on reports uploaded by a transcription vendor. Identifies reviews, verifies, and corrects all statistical data concerning medical transcription to maintain accuracy of medical and statistical reports. Works with interdisciplinary staff to solve problems regarding proper health record documentation and completion. Develops and compiles written reports trending provider specific, service, and hospital compliance reports regarding admission subsequent and discharge notes. The duties listed above are for full performance level (GS-7), developmental grade level duties will be of lower complexity and greater supervision. Work Schedule:
8:
00 am - 4:
30 pm, Monday - Friday Financial Disclosure Report:
Not required 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. AND English Language Proficiency:
MRTs HIT must be proficient in spoken and written English, as required by 38 U.S.C. 7403(f). AND
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:
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. OR Experience/Education Combination:
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). 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):
Experience or Education:
One year of experience equivalent to the next lower level (GS-4). OR 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). AND Demonstrated Knowledge, Skills, and Abilities (KSA's):
(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:
Experience:
One year of experience equivalent to the next lower grade level (GS-5). AND Demonstrated KSA's:
(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):
Experience:
One year of experience equivalent to the next lower grade level (GS-6). AND Demonstrated KSA's:
(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. References:
VA Handbook 5005/124, Part II, Appendix G59, December 10, 2019 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:
Moderate lifting (15-44 lbs); use of fingers; use of both hands; walking, standing, repeated bending for 1 hour; ability to see a computer screen; hearing aids are permitted. Environmental factors include working alone or working closely with others.
- Department:
0675 Medical Records Technician - Salary Range:
$31,208 to $56,222 per year
Estimated Salary: $20 to $28 per hour based on qualifications.
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