MEDICAL RECORDS TECH (HIT)

Summary This position is located in the Health Information Management (HIM) section at the VA Eastern Kansas Health Care System. Medical Records Technicians (MRT) Health Information Technicians (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. Responsibilities The VA Eastern Kansas Health Care System is committed to Diversity and Inclusion. Together, we strive to create and maintain a working and learning environment that promotes professional growth and teamwork. We offer an inclusive, equitable, and welcoming environment where we celebrate our individual differences and unite as a team toward a common goal of providing outstanding service to our Nations Veterans. Duties of this position include but are not limited to: The incumbent is responsible for abstraction of clinical information for ongoing regulatory reviews and advising the clinical treatment team on issues related to record completion and documentation requirements. Contacts physicians and other ancillary service personnel regarding dictation and/or signatures. Assists medical staff by providing information as to required documentation. Communicates very closely with the medical staff to answer questions and resolve problems to insure quality documentation in the health records. Prepares lists of paper health records needed for signature(s) that are located in the incomplete record area for distribution to appropriate service lines (i.e., Medicine, Surgery, Psychiatry, etc.) or that are not complete in the electronic health record. Monitors delinquent dictation list for follow-up purposes on necessary documents (i.e., operation reports, discharge summaries, etc.) that are needed for completion of health records. Notifies appropriate physician and other personnel of the status of dictation. Monitors house staff rotation schedule and contacts resident house staff to insure completion of records prior to departure from the Medical Center. Utilizes basic knowledge of medical terminology, anatomy and physiology, and coding to research and collect information for various medical studies and research projects utilizing the Patient Treatment File (PTF) and PTF microfiche. Conducts periodic audit of records processing activities. Participates in approved quality improvement focused reviews. Coordinates review activities with the Quality Improvement Program to satisfy external accreditation requirements, and to satisfy current Medical Center performance measures. Assists with capture and reporting of health record documentation deficiencies as needed including downloading data and creating trended reports. 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. Makes appropriate recommendations for changes or solutions and facilitate appropriate recommendations for corrective action when authorized so continued filing errors do not occur. Identifies reviews, verifies, and corrects all statistical data concerning medical transcription to maintain accuracy of medical and statistical reports. Compares and resolves discrepancies between daily Gains and Losses Sheet, Digital System Workload Report and contract transcription logs as it relates to timeliness and accuracy of dictated reports completed by medical transcription contractor. Work Schedule: Monday- Friday 8:00am – 4:30pm Telework: Ad-Hoc Virtual: This is not a virtual position. Functional Statement #: 000000 Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized Requirements Conditions of Employment 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. 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. 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. 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 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, 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) (1) Experience or Education. None beyond basic requirements Medical Records Technician (HIT), GS-5 (Developmental Level 1) (1) Experience. One year of experience equivalent to the next lower level. OR, (2) Education. A bachelors 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. 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 (1) Experience. One year of 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: (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. Medical Records Technician (HIT), GS-7 (Full Performance Level) (1) Experience. One year of 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: (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. Preferred Experience: Health information management skills, medical terminology, A&P, Excel & Word skills, data analysis, administrative skills, and communication skills Reference: For more information on this qualification standard, please visit https://www.va.gov/ohrm/QualificationStandards/. VHA Handbook 5005/124, Part II Appendix G59, MEDICAL RECORDS TECHNICIAN (HEALTH INFORMATIONTECHNICIAN) QUALIFICATION STANDARD. The full performance level of this vacancy is GS7. 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: Mostly sedentary work performed in an office setting. Physical aspects associated with work required of this assignment are typical for the occupation and would generally not require a pre-placement examination. Education IMPORTANT: A transcript must be submitted with your application if you are basing all or part of your qualifications on education. Note: Only education or degrees recognized by the U.S. Department of Education from accredited colleges, universities, schools, or institutions may be used to qualify for Federal employment. You can verify your education here: http://ope.ed.gov/accreditation/. If you are using foreign education to meet qualification requirements, you must send a Certificate of Foreign Equivalency with your transcript in order to receive credit for that education. For further information, visit: https://sites.ed.gov/international/recognition-of-foreign-qualifications/. Additional Information Receiving Service Credit or Earning Annual (Vacation) Leave: Federal Employees earn annual leave at a rate (4, 6 or 8 hours per pay period) which is based on the number of years they have served as a Federal employee. Selected applicants may qualify for credit toward annual leave accrual, based on prior work experience or military service experience. This credited service can be used in determining the rate at which they earn annual leave. Such credit must be requested and approved prior to the appointment date and is not guaranteed. During the application process you may have an option to opt-in to make your resume available to hiring managers in the agency who have similar positions. Opting in does not impact your application for this announcement, nor does it guarantee further consideration for additional positions. This job opportunity announcement may be used to fill additional vacancies. This position is in the Excepted Service and does not confer competitive status. VA encourages persons with disabilities to apply. The health-related positions in VA are covered by Title 38, and are not covered by the Schedule A excepted appointment authority. Pursuant to VHA Directive 1193.01, VHA health care personnel (HCP) are required to be fully vaccinated against COVID-19 subject to such accommodations as required by law (i.e., medical, religious or pregnancy). VHA HCPs do not include remote workers who only infrequently enter VHA locations. If selected, you will be required to be fully vaccinated against COVID-19 and submit documentation of proof of vaccination before your start date. The agency will provide additional information regarding what information or documentation will be needed and how you can request a legally required accommodation from this requirement using the reasonable accommodation process. If you are unable to apply online or need an alternate method to submit documents, please reach out to the Agency Contact listed in this Job Opportunity Announcement. Under the Fair Chance to Compete Act, the Department of Veterans Affairs prohibits requesting an applicants criminal history prior to accepting a tentative job offer. For more information about the Act and the complaint process, visit Human Resources and Administration/Operations, Security, and Preparedness (HRA/OSP) at The Fair Chance Act.