Medical Records Technician (Health Information Technician)
Medical Records Technician (Health Information Technician) (MRT HIT) performs incomplete health record analysis; review, analyze, abstract, maintain, extract, and compile information from the health record; and check for accuracy, completeness, and timeliness of the health record and monitor and report for regulatory compliance. The following major functions and responsibilities are for the full performance level (GS-07) for this position. Employees at lower grade level will receive supervision/guidance from the supervisory MRT HIT or designee. Major functions and responsibilities include but are not limited to:
Serve as technical expert in health record content and documentation requirements Review records for adherence with CMS guidelines related to student, resident supervision and attending physician presence and documentation Review health records to ensure that all records contain sufficient information to meet medical/legal requirements, to ensure continuity of patient care, and to support education and research needs Perform the quantitative and qualitative analysis on both computer and paper based health records Identify health record deficiencies, track deficiencies and ensure that the appropriate individual completes their deficiencies Expedite 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 Assess the paper health record and electronic Computerized Patient Record System (CPRS) for completeness and note deficiencies Track electronic signatures and documents deficiencies and communicates these deficiencies to clinical staff for correction Prepare complex weekly and monthly reports noting the status of all incomplete/delinquent records and compliance reports and submit the reports to the appropriate administrative and clinical staff Preform analytical tasks associated with the resolution of filing errors on reports uploaded by a transcription vendor Identify, review, verify, and correct all statistical data concerning medical transcription to maintain accuracy of medical and statistical reports Review health records for adherence with guidelines related to resident supervision and attending physician presence Work with interdisciplinary staff to solve problems regarding proper health record documentation and completion Develop and comply written reports trending provider specific, service, and hospital compliance reports regarding admission subsequent and discharge notes Prepare weekly and monthly reports noting the status of all incomplete/delinquent health records and submit the reports to the appropriate administrative and clinical staff Work Schedule:
Monday to Friday; 08:
00 a.m. to 4:
30 p.m. Financial Disclosure Report:
Not required To qualify for this position, applicants must meet all requirements by the closing date of this announcement, 02/12/2020. 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. 1 year of creditable experience that indicates knowledge of medical terminology, anatomy, physiology, and a general understanding of health records. 6 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). (UNOFFICIAL TRANSCRIPT REQUIRED:
If you do not submit your transcript, your application will not be reviewed.) 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) 6 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 6 semester hours of health information technology/health information management; (b) 6 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. English Language Proficiency. MRTs HIT must be proficient in spoken and written English, as required by VA Policy. 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). Grandfathering Provision:
All persons employed in VHA as a MRT HIT, on the effective date of this qualification standard (December 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. Grade Determinations:
In addition to the basic requirements of employment, the following criteria must be met when determining the grade of candidates. Medical Records Technician (HIT), GS-4 (Entry Level):
None beyond basic requirements. Medical Records Technician (HIT), GS-5 (Developmental Level 1):
Experience. 1 year of experience equivalent to the next lower level (GS-4). Qualifying specialized experience is an entry level MRT HIT experience analyzing health records for accuracy, completeness, timeliness, consistency, and compliance (e.g., scanned, uploaded, use of correct titles, linked to correct encounters, etc.), with HIM industry standards, policies, procedures, laws, regulations, and accrediting bodies; performing health record review activities to satisfy external accreditation requirements and medical center performance measures; and monitoring, verifying, correcting, and uploading all transcription/medical speech recognition to maintain completeness and accuracy of health records. 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). AND Demonstrated Knowledge, Skills, and Abilities. In addition to the experience or education above, the candidate must demonstrate all of the following KSAs:
See Demonstrated KSAs under 'Education.' Medical Records Technician (HIT), GS-6:
Experience. 1 year of experience equivalent to the next lower grade level (GS-5). Qualifying specialized experience is a developmental level MRT HIT experience analyzing health records for accuracy, completeness, timeliness, consistency, and compliance with HIM industry standards, policies, procedures, laws, regulations, and accreditation requirement; performing health record review activities to satisfy external accreditation requirements and medical center performance measures; creating and monitoring reports to ensure that deficiencies are resolved and completed appropriately; monitoring, verifying, correcting, and/or uploading all transcription/medical speech recognition to maintain completeness and accuracy of health records; notifying clinical providers regarding incomplete health records; and assisting clinical providers regarding completeness of their health record documentation. AND Demonstrated Knowledge, Skills, and Abilities. In addition to the experience above, the candidate must demonstrate all of the following KSAs:
See Demonstrated KSAs under 'Education.' Medical Records Technician (HIT), GS-7 (Full Performance Level):
Experience. 1 year of experience equivalent to the next lower grade level (GS-6). Qualifying specialized experience is a developmental level MRT HIT experience analyzing, abstracting, maintaining, extracting and compiles information from the health record, working under the review of the supervisor; analyzing health records for accuracy, completeness, timeliness, consistency, and compliance with HIM industry standards, policies, procedures, laws, regulations, and accreditation requirements; coordinating and/or performing health record review activities to satisfy external accreditation requirements and medical center performance measures; notifying clinical providers regarding incomplete health records; assisting clinical providers regarding completeness of their health record documentation, and the correction of health records; conducting reviews of incomplete records for individuals clearing the facility; creating and monitoring reports to ensure that deficiencies are resolved and completed appropriately; monitoring, verifying, correcting, and/or uploading all transcription/medical speech recognition to maintain completeness and accuracy of health records; and serving as the technical experts in health record content and documentation requirements. AND Demonstrated Knowledge, Skills, and Abilities. In addition to the experience above, the candidate must demonstrate all of the following KSAs:
See Demonstrated KSAs under 'Education.' References:
VA Handbook 5005/124, Part II, Appendix G59. Medical Records Technician (HIT) Qualification Standard GS-0675. This can be found in the local Human Resources Office. The full performance level of this vacancy is GS-7. The actual grade at which an applicant may be selected for this vacancy is in the range of GS-4 to GS-7. Physical Requirements:
This is a sedentary position, working behind a monitor so the ability to see (i.e. correctable vision) is necessary. The working space is wheelchair accessible and may require lifting of no more than 10 lbs.
Estimated Salary: $20 to $28 per hour based on qualifications.
Serve as technical expert in health record content and documentation requirements Review records for adherence with CMS guidelines related to student, resident supervision and attending physician presence and documentation Review health records to ensure that all records contain sufficient information to meet medical/legal requirements, to ensure continuity of patient care, and to support education and research needs Perform the quantitative and qualitative analysis on both computer and paper based health records Identify health record deficiencies, track deficiencies and ensure that the appropriate individual completes their deficiencies Expedite 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 Assess the paper health record and electronic Computerized Patient Record System (CPRS) for completeness and note deficiencies Track electronic signatures and documents deficiencies and communicates these deficiencies to clinical staff for correction Prepare complex weekly and monthly reports noting the status of all incomplete/delinquent records and compliance reports and submit the reports to the appropriate administrative and clinical staff Preform analytical tasks associated with the resolution of filing errors on reports uploaded by a transcription vendor Identify, review, verify, and correct all statistical data concerning medical transcription to maintain accuracy of medical and statistical reports Review health records for adherence with guidelines related to resident supervision and attending physician presence Work with interdisciplinary staff to solve problems regarding proper health record documentation and completion Develop and comply written reports trending provider specific, service, and hospital compliance reports regarding admission subsequent and discharge notes Prepare weekly and monthly reports noting the status of all incomplete/delinquent health records and submit the reports to the appropriate administrative and clinical staff Work Schedule:
Monday to Friday; 08:
00 a.m. to 4:
30 p.m. Financial Disclosure Report:
Not required To qualify for this position, applicants must meet all requirements by the closing date of this announcement, 02/12/2020. 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. 1 year of creditable experience that indicates knowledge of medical terminology, anatomy, physiology, and a general understanding of health records. 6 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). (UNOFFICIAL TRANSCRIPT REQUIRED:
If you do not submit your transcript, your application will not be reviewed.) 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) 6 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 6 semester hours of health information technology/health information management; (b) 6 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. English Language Proficiency. MRTs HIT must be proficient in spoken and written English, as required by VA Policy. 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). Grandfathering Provision:
All persons employed in VHA as a MRT HIT, on the effective date of this qualification standard (December 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. Grade Determinations:
In addition to the basic requirements of employment, the following criteria must be met when determining the grade of candidates. Medical Records Technician (HIT), GS-4 (Entry Level):
None beyond basic requirements. Medical Records Technician (HIT), GS-5 (Developmental Level 1):
Experience. 1 year of experience equivalent to the next lower level (GS-4). Qualifying specialized experience is an entry level MRT HIT experience analyzing health records for accuracy, completeness, timeliness, consistency, and compliance (e.g., scanned, uploaded, use of correct titles, linked to correct encounters, etc.), with HIM industry standards, policies, procedures, laws, regulations, and accrediting bodies; performing health record review activities to satisfy external accreditation requirements and medical center performance measures; and monitoring, verifying, correcting, and uploading all transcription/medical speech recognition to maintain completeness and accuracy of health records. 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). AND Demonstrated Knowledge, Skills, and Abilities. In addition to the experience or education above, the candidate must demonstrate all of the following KSAs:
See Demonstrated KSAs under 'Education.' Medical Records Technician (HIT), GS-6:
Experience. 1 year of experience equivalent to the next lower grade level (GS-5). Qualifying specialized experience is a developmental level MRT HIT experience analyzing health records for accuracy, completeness, timeliness, consistency, and compliance with HIM industry standards, policies, procedures, laws, regulations, and accreditation requirement; performing health record review activities to satisfy external accreditation requirements and medical center performance measures; creating and monitoring reports to ensure that deficiencies are resolved and completed appropriately; monitoring, verifying, correcting, and/or uploading all transcription/medical speech recognition to maintain completeness and accuracy of health records; notifying clinical providers regarding incomplete health records; and assisting clinical providers regarding completeness of their health record documentation. AND Demonstrated Knowledge, Skills, and Abilities. In addition to the experience above, the candidate must demonstrate all of the following KSAs:
See Demonstrated KSAs under 'Education.' Medical Records Technician (HIT), GS-7 (Full Performance Level):
Experience. 1 year of experience equivalent to the next lower grade level (GS-6). Qualifying specialized experience is a developmental level MRT HIT experience analyzing, abstracting, maintaining, extracting and compiles information from the health record, working under the review of the supervisor; analyzing health records for accuracy, completeness, timeliness, consistency, and compliance with HIM industry standards, policies, procedures, laws, regulations, and accreditation requirements; coordinating and/or performing health record review activities to satisfy external accreditation requirements and medical center performance measures; notifying clinical providers regarding incomplete health records; assisting clinical providers regarding completeness of their health record documentation, and the correction of health records; conducting reviews of incomplete records for individuals clearing the facility; creating and monitoring reports to ensure that deficiencies are resolved and completed appropriately; monitoring, verifying, correcting, and/or uploading all transcription/medical speech recognition to maintain completeness and accuracy of health records; and serving as the technical experts in health record content and documentation requirements. AND Demonstrated Knowledge, Skills, and Abilities. In addition to the experience above, the candidate must demonstrate all of the following KSAs:
See Demonstrated KSAs under 'Education.' References:
VA Handbook 5005/124, Part II, Appendix G59. Medical Records Technician (HIT) Qualification Standard GS-0675. This can be found in the local Human Resources Office. The full performance level of this vacancy is GS-7. The actual grade at which an applicant may be selected for this vacancy is in the range of GS-4 to GS-7. Physical Requirements:
This is a sedentary position, working behind a monitor so the ability to see (i.e. correctable vision) is necessary. The working space is wheelchair accessible and may require lifting of no more than 10 lbs.
- Department:
0675 Medical Records Technician - Salary Range:
$35,638 to $64,203 per year
Estimated Salary: $20 to $28 per hour based on qualifications.
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