Medical Records Technician - Health Information Technician

Summary

Located in the Health Information Management (HIM) section at the Sheridan Wyoming VA Medical Center. MRTs HIT perform incomplete health record analysis. They review, analyze, abstract, maintain, extract, & compile information from the health record. MRTs HIT check for accuracy, completeness, & timeliness of the health record & monitor & report for regulatory compliance. Routinely scans paper and electronic documents to the EHR ensuring proper and timely placement in the medical record.

Duties

Serves as technical expert in health record content and documentation requirements. Responsible for performing quantitative and qualitative reviews of health record documentation for ongoing regulatory reviews and deficiency analysis. Responsible for ensuring that all patient care data entered in the electronic health record (EHR) is accurate, timely, and complete. Adheres to established documentation requirements as outlined by The Joint Commission (TJC) regulations, Veterans Health Administration (VHA) guidelines, as well as medico-legal requirements. Reviews health records for adherence with the Centers for Medicare and Medicaid Services (CMS) guidelines related to student, resident supervision and attending physician presence and documentation. Compiles reports to ensure provider specific and service compliance. Maintains a control system to ensure completion of all inpatient and outpatient health records in accordance with VHA, TJC, CMS and other regulatory agencies' standards. Reviews health records to ensure that all health records contain sufficient information to meet medico-legal requirements, to ensure continuity of patient care, and to support education and research needs. Notifies clinicians of missing, incomplete, or inaccurate information in their signature blocks (e.g., missing or inaccurate credentials). Assist clinicians with completion of delinquent/incomplete health records. Assesses the health record for completeness, identifies health record deficiencies, tracks deficiencies, and ensures that the appropriate individuals complete their deficiencies. Notates documentation deficiencies in the appropriate deficiency monitoring application. Tracks unsigned/un-cosigned notes (e.g., progress notes, operative reports, discharge summaries, etc.) and encounters without associated progress notes and communicates these deficiencies to clinical staff for completion. Notification can be in person, through secure email, via telephone, or through other acceptable means. Responsible for expediting the completion of the health record when the patient is transferred for care at another medical center, for legal requests, regulatory agencies review, and reimbursement purposes. Performs 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 to and filing/assigning it correctly. If site utilizes Dragon and assigns medical speech recognition (MSR) duties to the HIM Department, coordinates and monitors the use of medical speech recognition and troubleshoots with clinicians, as needed, to maintain completeness and accuracy of health records. Provides Dragon Local Administrator duties that typically include: creating new user accounts in the Nuance Management Center, act as a local POC for Dragon questions, referrals and guidance, troubleshoot technical problems with local IT as needed, assist clinical end users with log on and provide user guides, create and maintain a facility Dragon User Outlook mail group to facilitate MSR communications, submit tickets to Nuance Government Support, as needed, listen in and participate on the VHA MSR Administration calls, provide training tools and resources, facilitate purchase and distribution of headsets/microphones as needed, and provide Dragon usage reports to leadership. Works with interdisciplinary staff to solve problems regarding proper health record documentation and completion. Consults with the appropriate clinician(s) for clarification when conflicting or ambiguous information appears in the health record documentation. Prepares complex reports on a routine basis, noting the status of all incomplete/delinquent health records, and submits the reports to the appropriate administrative and clinical staff. Develops and compiles written reports trending provider specific, service, and hospital compliance reports regarding admission, subsequent and discharge progress notes. Obtains statistical information, applies statistical formulas, and completes statistical reports for medical center management. Work Schedule: Monday - Friday, 7:30am - 4:00pm Telework: Available on an ad-hoc basis. Virtual: This is not a virtual position. Functional Statement #: 61593-0 / 61594-0 / 61595-0 / 61596-0 Relocation/Recruitment Incentives: Not authorized. Permanent Change of Station (PCS): 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. 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. Grandfathering Provision. All persons employed in VHA as a MRT HIT, on the effective date of this qualification standard (12/10/2019), 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. For employees who do not meet all the basic requirements in this standard, but who met the qualifications applicable to the position at the time they were appointed to it, the following provisions apply: Such employees in an occupation that does not require a licensure/certification/ registration, may be reassigned, promoted, or demoted within the occupation, but will not be promoted beyond the journey level or placed in s