Medical Records Technician (Release of Information)

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

Citizenship: Must be a citizen of the United States. Non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy. English Language Proficiency. Medical Records Technicians (ROI) must be proficient in spoken and written English, as required by 38 U.S.C. § 7403(f). A) Experience: One year of experience that indicates knowledge of medical terminology and general understanding of the health records.

Six months of the required one year of creditable experience must have provided the knowledge, skill, and abilities (KSA's) needed to perform MRT (ROI) work. OR B) Education: An associates 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 and physiology, legal aspects of health care, and introduction to health records).

OR C) Experience/Education Combination: Equivalent combinations of experience and education are qualifying towards meeting basic experience requirements.

The following experience and education/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 courses.

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 Armed Forces or the U.S. Maritime Service under close medical and professional supervision.

The training program may be substituted on a month-for-month basis for up to six months of experience provided the training program included courses in anatomy and physiology, and health record techniques and procedures. Grandfathering Provision.

All persons employed in VHA as a MRT (ROI) on the effective date of this qualification standard are considered to have met all qualification requirements for the grade held, including positive education and licensure/certification/registration that are part of the basic requirements of the occupation.

02Grade Determinations

Medical Records Technician (ROI) GS-4: Experience or Education. None beyond basic requirements. Medical Records Technician (ROI) GS-5: Experience. One year of creditable experience equivalent to the next lower grade level; 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). 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. 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.

Reference: For more information on this qualification standard, please visit https://www.va.gov/ohrm/QualificationStandards/.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.

03Physical Requirements

The work is mostly sedentary. It typically requires sitting with sustained periods of concentration. There will be some walking, standing, bending, and carrying of relatively light objects. The position may also require stooping, reaching, lifting, pulling, and other moderate exertion or strain. Incumbent may occasionally have to walk some distance to a meeting.

The duties of the Medical Records Technician (ROI) include, but are not limited to: Responsible for evaluating the validity and adequacy of each release of information request. Screens each request for information to determine urgency and assures that most urgent requests are completed fist using established priority systems. Greets veterans/visitors and assists them in determining the exact nature of the request and whether the information requested can be released.

Applies public laws, rules, regulations and exclusions governing confidentiality of the medical record, including the Privacy Act, Freedom of Information Act and 38 U.S.C. 7332 governing the release of records containing information regarding the treatment of or referral for drug and/or alcohol abuse, Sickle Cell Anemia and infection with Human Immunodeficiency Virus (HIV).

Processes 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. 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) and ensures that proper authorization exists before release is made.

Provides advisory and technical assistance to patients, administrative staff and professional staff regarding release of information. Inquiries vary widely and information given requires explanation of office functions, describing specific requirements, providing basic instructions, or a similar degree of detail. 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; ensures the information released is limited to what is specifically authorized and to the person or agency designated to receive it.

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. This 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.

Replies to vague, incomplete, or ambiguous inquires by independently recognizing issues, topics or problems. 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: Monday - Friday, 8:00am - 4:30pm Compressed/Flexible: Not Available Virtual: This is not a virtual position.

Functional Statement #: 91761A (GS-4), 91762A (GS-5), 91763A (GS-6) Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized