Medical Records Technician (Health Information Technician)

Summary

This position is located in the Health Information Management (HIM) section of the Health Administrative Service (HAS) at the St Cloud VA Medical Center (SCVA-HCS). MRT (HIT) perform incomplete health record analysis. They review, analyze, abstract, maintain, extract, and compile information from the health record. MRT (HIT) check for accuracy, completeness, and timeliness of the health record and monitor and report for regulatory compliance.

Duties

The incumbent is required to physically report to and work from the St. Cloud, MN office Major Duties includes, but are not limited to: Incumbent serves as technical expert in health record content and documentation requirements. Incumbent is responsible for performing quantitative and qualitative reviews of health record documentation for ongoing regulatory reviews and deficiency analysis. Incumbent is responsible for ensuring that all patient care data entered in the electronic health record (EHR) is accurate, timely, and complete. 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 insure provider specific and service compliance. Maintains a control system to ensure completion of all inpatient and outpatient health records in accordance with Veterans Health Administration (VHA), The Joint Commission (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). Assists 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 electronic signatures and documents deficiencies and communicates these deficiencies to clinical staff for correction. 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. Duties includes the generation of various statistical reports to track these errors. Makes appropriate recommendations for changes or solutions and implements appropriate recommendations for corrective action when authorized so continued filing errors do not occur. 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. Performs administrative corrections to the health record, such as correcting note titles, designating correct signer/cosigner, ensuring notes are attached to the correct episode of care, etc. Utilizes EHR functionality to analyze, manage and monitor documentation and data capture deficiencies and to communicate with staff to resolve deficiencies in accordance with facility policies and performance goals. Identifies incomplete health records for individuals clearing the facility and assists clinicians with the clearance process for health records. Work Schedule: Monday-Friday, 7:30am-4:00pm Telework: Not Available Virtual: This is not a virtual position. Functional Statement #: 000000 Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized

Qualifications

Creditable Experience. Experience is only creditable if it is paid or non-paid employment directly related to the position to be filled, or in a related field, such as medical support assistants, clinic/ward clerks, health record file room/scanning technicians, medical coding, or other positions that include knowledge of the content and uses of health records. To be creditable, the candidate's experience must have demonstrated the use of knowledge, skills, and abilities associated with current MRT(HIT) practice. 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 and Education. (1) 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, (2) 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, (3) 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) 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 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: (a) Ability to communicate effectively with internal and extern