Medical Records Technician - Health Information Technician (HIT)

Summary

This position is located in the Health Information Management (HIM) section at the Veterans Affairs Illiana Health Care System (VAIHCS). MRTs HIT performs 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 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 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). 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 unsigned/uncosigned 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. 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. Collects, interprets, and trends data from data validation activities and audits that support continuity of patient care, budget/resource allocation, performance measurement, quality management, research, VA comparative analysis and benchmarking. Participates in routine and focused reviews for the purpose of identifying problems and potential problems in health record documentation as part of the health record review process. Identifies and abstracts information from health records for special studies and audits both internal and external. Work Schedule: 7:30 am-4:00 pm, Monday to Friday. 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) Telework: Not authorized. Virtual: This is not a virtual position. Functional Statement #: 02479F, 02481F, 02480F, 03202F

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. English Language Proficiency: Must be proficient in spoken and written English, as required by 38 U.S.C. 7403(f). Experience: One year of 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. This experience should include positions that required the knowledge of basic knowledge of medical terminology; basic knowledge of disease processes and human anatomy; basic knowledge of medical record/health information guidelines, techniques, and procedures; and knowledge of the medical and legal significance of medical records. OR Education: 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 and physiology, medical coding and introduction to health records). Transcripts Required. OR Combination Education and Experience: Equivalent combinations of creditable experience and education which are qualifying for meeting the basic requirements. The following educational/training substitutions are appropriate for combining education and experience: (a) Six months of creditable experience that indicates knowledge of medical terminology, privacy and release of information, the health record, and one (1) year above high school with a minimum of 6 semester hours of health information technology courses. (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 of medical technicians, hospital corpsmen, medical service specialists, or hospital training obtained in a training program given by the 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. Transcripts Required. Qualifications: In addition to the basic requirements above the following is the amount of experience required to qualify for this position at the GS-7 grade level. Grade Determinations: Medical Records Technician (HIT) GS-4 Experience or Education: None beyond basic requirements. Medical Records Technician (HIT) GS-5 Experience: One year of creditable experience equivalent to the next lower grade level; OR Education: Successful completion of 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 informatio