Medical Records Technician - Health Information Technician

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.

01Basic Requirements

United States Citizenship. Non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy. English Language Proficiency. MRTs HIT must be proficient in spoken and written English, as required by 38 U.S.C. § 7403(f). 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: (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.

02Grade 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. One year of experience equivalent to the next lower level (GS-4). 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). Demonstrated Knowledge, Skills, and Abilities (KSAs).

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 Experience. One year of experience equivalent to the next lower grade level (GS-5). Demonstrated Knowledge, Skills, and Abilities (KSAs).

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) Experience. One year of experience equivalent to the next lower grade level (GS-6). Demonstrated Knowledge, Skills, and Abilities (KSAs).

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.

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-7. The actual grade at which an applicant may be selected for this vacancy is in the range of GS-4 to GS-7.

03Physical Requirements

See VA Directive and Handbook 5019, Employee Occupational Health Service.

Total Rewards of a Allied Health Professional This position is located in the Health Information Management (HIM) section at the Cheyenne VA Medical Center. Major Duties and Responsibilities: The incumbent abstracts clinical information for ongoing regulatory reviews and deficiency analysis. Contacts physicians and other ancillary service personnel regarding dictation and/or signatures. Assist clinical staff by providing information on required documentation.

• Communicates very closely with the clinical staff to answer questions and resolve problems to ensure quality documentation in the health records.
• Assists with capture and reporting of health record documentation deficiencies and notates documentation deficiencies in the appropriate deficiency monitoring application.
• Monitors delinquent dictation lists for follow-up purposes on necessary documents (i.e., operation reports, discharge summaries, etc.) to complete health records.

Notify the appropriate physician and other personnel of the status of dictation. Monitors house staff rotation schedule and contacts resident house staff to ensure completion of health records before departure from the Medical Center. Performs analytical tasks to resolve "filing" errors on reports uploaded by a transcription vendor. This includes correctly identifying the patient to whom the report belongs and filing/assigning it correctly.

Identifies, reviews, verifies, and corrects all statistical data concerning medical transcription to maintain the accuracy of medical and statistical reports. Participates in approved quality improvement-focused reviews. Utilizes basic knowledge of medical terminology, anatomy and physiology, and coding to research and collect information for various medical studies and research projects.

Coordinates review activities with the Quality Improvement Program to satisfy external accreditation requirements and to meet current Medical Center performance measures. Collects data from data validation activities and audits supporting patient care continuity, budget/resource allocation, performance measurement, quality management, research, VA comparative analysis, and benchmarking.

The Health Information Technician performs under the direct supervision of the HIMs Chief with guidance from more senior staff members. Work Schedule: Monday - Friday, 8:00 am to 4:30 pm Compressed/Flexible: Not Available. Telework: Not Available. Virtual: This is not a virtual position. Functional Statement #: 442-52212-A; 442-52213-A; 442-52214-A; 442-52215-A Relocation/Recruitment Incentives: Not Authorized. Permanent Change of Station (PCS): Not Authorized.