Medical Records Technician Integrated (Health Information Technician)
What you'd do
This position is located in the Health Information Management (HIM) section at the Veterans Affairs Texas Valley Coastal Bend Health Care System. Medical Records Technician (MRTs) Health Information Technician (HIT) perform 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.
Major duties
Total Rewards of a Allied Health Professional The Medical Records Technician (MRT) Health Information Technician (HIT) Duties may include but are not limited to: Analyze health records for accuracy, completeness, timeliness, consistency and compliance (e.g scanned, uploaded, use of correct titles, linked to correct encounters etc) with Health Information Management (HIM) industry standards, policies, procedures, laws, regulations and accrediting bodies. Perform health record review activities to satisfy external accreditation requirements and medical center performance measures. Monitor, verify, correct and upload all transcription/medical speech recognition to maintain completeness and accuracy of health records. Monitor, verify, correct and/or upload all transcription/medical speech recognition to maintain completeness and accuracy of health records. Notify clinical providers regarding incomplete health records and assist clinical providers regarding completeness of their health record documentation. Analyzes, abstracts, maintains, extracts and compiles information from the health record, working under the review of the supervisor. Analyze health records for accuracy, completeness, timeliness, consistency, and compliance (e.g scanned, uploaded, use of correct titles, linked to correct encounters, etc) with Health Information Management (HIM) industry standards, policies, procedures, laws, regulations and accreditation requirements. Coordinate and/or perform health record review activities to satisfy external accreditation requirements and medical center performance measures. Notifies clinical providers regarding incomplete health records. Assist clinical providers regarding completeness of their health record documentation and the correction of health records. Conduct reviews of incomplete records for individuals clearing the facility. They create and monitor reports to ensure that deficiencies are resolved and completed appropriately. Monitor, verify, correct and/or upload all transcription/medical speech recognition to maintain completeness and accuracy of health records. Serve as the technical experts in health record content and documentation requirements. Work Schedule: Monday - Friday 0800am-0430pm Recruitment Incentive (Sign-on Bonus): Not Authorized Permanent Change of Station (Relocation Assistance): Not Authorized 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 #: 55525-F, 55526-F, 55527-F, 55528-F, Permanent Change of Station (PCS): Not Authorized PCS Appraised Value Offer (AVO): Not Authorized
What you need to qualify
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. 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 Medical Record Technician (MRT) Health Information Technician (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. 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 (Health Information Technician) GS-4 Entry Level Experience or Education: None beyond basic requirements. Medical Records Technician (Health Information Technician) GS-5 Developmental Level 1 Experience: One year of experience equivalent to the next lower level. 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). Demonstrated Knowledge Skills and Abilities: In addition to the experience above, the candidate must demonstrate all of the following KSAs: Ability to communicate effectively with internal and external customers. Ability to utilize health information technology and various office software products used in health information management positions (e.g Microsoft Excel, electronic health records and delinquency tracking software). Knowledge of health record documentation guidelines and industry standards. Ability to manage priorities and coordinate work to complete duties within required timeframes. Ability to apply knowledge of medical terminology and human anatomy to fully understand the content of a health record. Medical Records Technician (Health Information Technician) GS-6 Experience: One year of experience equivalent to the next lower grade level. Demonstrated Knowledge Skills and Abilities: In addition to the experience above, the candidate must demonstrate all of the following KSAs: Ability to navigate efficiently through the health record to locate needed information. Ability to analyze health record documentation to ensure compliance with guidelines and industry standards. Skill in investigating potential health record errors and making corrections, when appropriate. Skill in interpreting and applying health information guidelines and using 5 judgment to complete assignments. Ability to follow up on incomplete health record documentation. Medical Records Technician (Health Information Technician) GS-7 Full Performance Level Experience: One year of experience equivalent to the next lower grade level. Assignment. Demonstrated Knowledge, Skills and Abilities: In addition to the experience above, the candidate must demonstrate all of the following KSAs: - Ability to judge whether health records contain sufficient information for regulatory requirements, are acceptable as legal documents, are adequate for continuity of patient care, and support education and research needs. Ability to take appropriate actions if health record content is not adequate, accurate, timely and/or reliable. Ability to communicate both orally and in writing with individuals or groups, to facilitate compliance with established policies and regulations. Skill in using appropriate software and computer applications to analyze and record documentation trends. Ability to apply qualitative and/or quantitative methods for assessment and improvement of health records. Ability to work independently and utilize problem-solving techniques in the accomplishment of work. Preferred 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 Medical Records Technician Health Information Technician work. 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). Reference: For more information on this qualification standard, please visit https://www.va.gov/ohrm/QualificationStandards/. The full performance level of this vacancy is 07. The actual grade at which an applicant may be selected for this vacancy is in the range of 04 to 07. Physical Requirements: Physical aspects associated with work required of this assignment are typical for the occupation, see Duties section for essential job duties of the position. May require standing, lifting, carrying, sitting, stooping, bending, puling, and pushing. May be required to wear personal protective equipment and undergo annual TB screening or testing as conditions of employment.
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