Medical Records Technician - Health Information Technician

Summary

This position is located in the Health Information Management Service at the James A. Haley Veterans' Hospital and Clinics. The incumbent processes all incoming requests to the facility for Release of Information (ROI) along with required by the VA Regional Office through the Automated Medical Information Exchange (AMIE). This position supports coordination of resolution for all issues, Medical Record Review Committee, and notification to clinicians for records to complete.

Duties

This position is located in the Health Information Management Service, James A. Haley VA Medical Center in Tampa, FL. Medical Records Technician (Release of Information) discloses health information in accordance with all laws and regulations governing authorization and disclosure of health information. Duties listed but not limited to: Evaluates validity of each request. 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) Ensures that proper authorization exists before release is made. Processes the request to the requesting agency or individual. Inputs all requests into the ROI computer package for logging and tracking of these requests. Receives and directs callers and visitors. Receives and/or gives out forms and assists visitors and/or callers with the completion of forms or documents. Responds to questions from patients concerning services. 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 similar degree or detail. Searches records or files to compose responses, including electronic searches to retrieve and summarize hard-to-locate date. Locates materials that would verify information given. Incumbent is responsible for evaluating the adequacy of each completed authorization form Screens each request for information to determine urgency and assures that most urgent requests are completed first using established priority system. Personally greets veterans/visitors, 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 for drug and/or alcohol abuse, Sickle Cell Anemia, and infection with Human Immunodeficiency Virus (HIV). The incumbent processes all incoming requests to the facility for Release of Information (ROI) along with required by the VA Regional Office through the Automated Medical Information Exchange (AMIE). Evaluates validity of each request. 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). Employee composes responses to routine requests for release of patient information. Selects and compiles information from health records and prepares correspondence, typically using standard from or standard formats for letters. Ensures the information releases 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 words and expressions to convey the desired tone. Determines extent and tone or replies independently. 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. Processes Social Security request for health information using ROI software. Downloads VistA imaging documents and ROI software documents onto a secure Network Drive. Accesses the secure Social Security Web page and uploads the documents to the Web portal. Transfers the confirmation codes to the ROI software package and closes the request(s) in both the ROI and Social Security packages. Completes and processes routine release 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. That the terminology used by the clinicians is in keeping with the accepted nomenclature (standard approved abbreviations). That the 'Do Not Use' Abbreviations are not used. That the record is internally consistent and documentation filed within the record in the established sequence. That all necessary components are present and complete (i.e. progress notes, operation reports, history and physicals, discharge summaries, consultations, treatment records and signatures) and on the correct patient. Work Schedule: Monday through Friday, 8:00 AM 04:30 PM Compressed/Flexible: As needed by department Telework: Not Available Virtual: This is not a virtual position. Relocation/Recruitment Incentives: Not Authorized PCS Appraised Value Offer (AVO): Not Authorized

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. In accordance with 38 U.S.C. 7402(d), no person shall serve in direct patient care positions unless they are proficient in basic written and spoken English. 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 for meeting the basic 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. Grandfathering Provision. All persons employed in VHA as a MRT HIT, 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