Medical Records Technician (Health Information Technician)

Summary

This position is located in the Health Information Management (HIM) section of the Patient Business Service at the John D. Dingell VAMC. Medical Record Technicians (MRT) Health Information Technician (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.

Duties

Total Rewards of a Allied Health Professional Major duties include, but are not limited to: Analyze, validate, and maintain Patient Treatment Files (PTFs) for inpatient, observation, fee-basis, and non-VA patients. Ensure the accuracy, completeness, transmission, and timely closure of PTF records. Monitor, research, and resolve PTF, census, and transmission errors. Perform quantitative and qualitative reviews of health records for compliance with VHA, Joint Commission, and medical-legal requirements. Identify, track, and communicate documentation deficiencies to providers and clinical staff. Review health records for completeness, accuracy, timeliness, and consistency. Conduct quality assurance reviews and support DRG validation activities. Analyze patient demographic, eligibility, admission, transfer, and discharge data for accuracy. Prepare and maintain spreadsheets, statistical reports, compliance reports, and error-tracking logs. Audit health records and abstract information for studies, reviews, and accreditation requirements. Submit weekly, monthly, quarterly, and annual reports on record completion and compliance. Review and validate Edit Analysis Lists (EALs), census data, and disposition reports. Collaborate with coding staff, providers, and interdisciplinary teams to resolve documentation and data discrepancies. Serve as a resource on health record documentation standards and record completion requirements. Ensure documentation in VistA, CPRS, Nuance, and related systems is accurate, timely, and complete. Monitor delinquent records and facilitate timely provider completion of deficiencies. Analyze trends, generate recommendations, and support corrective actions to improve data quality and compliance. Assist with quarterly and annual census reporting and validation activities. Work Schedule: Monday-Friday, 8:00a-4:30p. Schedule may be subject to change based on the needs of the Agency. Telework: Not Available Virtual: This is not a virtual position. Pay: Competitive salary and regular salary increases When setting pay, a higher step rate of the appropriate grade may be determined after consideration of higher or unique qualifications or special needs of the VA (Above Minimum Rate of the Grade). Paid Time Off: 37-50 days of annual paid time offer per year (13-26 days of annual leave, 13 days of sick leave, 11 paid Federal holidays per year)Selected applicants may qualify for credit toward annual leave accrual, based on prior [work experience] or military service experience. Parental Leave: After 12 months of employment, up to 12 weeks of paid parental leave in connection with the birth, adoption, or foster care placement of a child. Child Care Subsidy: After 60 days of employment, full time employees with a total family income below $144,000 may be eligible for a childcare subsidy up to 25% of total eligible childcare costs for eligible children up to the monthly maximum of $416.66. Retirement: Traditional federal pension (5 years vesting) and federal 401K with up to 5% in contributions by VA Insurance: Federal health/vision/dental/term life/long-term care (many federal insurance programs can be carried into retirement) Functional Statement #: 94451-A, 94452-A, 94453-A, 94454-A Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized VA Healthcare System advocates for a Whole Health System of care in each of the Medical Centers. This is an approach to healthcare that empowers and equips people to take charge of their health and well-being and live their lives to the fullest. As an employee operating in a Whole Health System of care, you will operate in a model with three core elements, seeking to create a personalized health plan for each Veteran. This is done in the context of healing relationships and healing environments and a connection back to the Veteran's community. This aligns with the Veterans Health Administration (VHA) Mission Statement to Honor America's Veterans by providing exceptional health care that improves their health and well-being.

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. 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. 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: MRT (HIT), GS-04 Experience or Education. None beyond basic requirements. MRT (HIT), GS-05 Experience. One year of experience equivalent to the next lower level. 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. In addition to the experience above, the candidate must demonstrate all of the following KSAs: Ability to communicate effectively with internal and external customers. Ability to utilize health information technology and various office software produ