This position is located in the Health Information Management (HIM) section at the Washington DC VA Medical Center. The incumbent will perform incomplete health record analysis. Review, analyze, abstract, maintain, extract, and compile information from the health record. Check for accuracy, completeness, and timeliness of the health record and monitor and report for regulatory compliance.
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. MRTs HIT must be proficient in spoken and written English 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: In addition to the Basic Requirements, the following criteria must be used when determining the appropriate grade assignment of candidates: GS-8 Lead Medical Records Technician (HIT) Experience: one year of experience at the next lower grade level (GS-7) that demonstrates the technical competencies described at that level. Assignment. This is considered the journey level for MRTs HIT. MRTs HIT at this level review, analyze, abstract, maintain, extract, and compile information from the health record independently with minimal supervision. They analyze 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 accreditation requirements. They also coordinate and/or perform health record review activities to satisfy external accreditation requirements and medical center performance measures. They communicate regularly with staff at various levels of the organization regarding delinquent health records and notify individual clinical providers regarding incomplete medical records. MRTs HIT prepare complex reports, calculate department statistics, note the status of all incomplete/delinquent records, and submit reports to the appropriate administrative and clinical staff and committees/leadership to ensure deficiencies are resolved and completed appropriately. They serve as the expert resource for clinical staff and assist clinical providers with the completion or correction of their health record documentation. They conduct the review of incomplete records for individuals clearing the facility. MRTs HIT coordinate the use of medical speech recognition/transcription and monitor, verify, troubleshoot, correct, and/or upload all transcription/medical speech recognition to maintain the completeness and accuracy of health records. They serve as the technical expert in health record content and documentation requirements. (a) 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. (b) Ability to take appropriate actions if health record content is not adequate, accurate, timely, and/or reliable. (c) Ability to communicate both orally and in writing with individuals or groups, to facilitate compliance with established policies and regulations. (d) Skill in using appropriate software and computer applications to analyze and record documentation trends. (e) Ability to apply qualitative and/or quantitative methods for assessment and improvement of health records. (f) Ability to work independently and utilize problem-solving techniques in the accomplishment of work. AND Demonstrated Knowledge, Skills, and Abilities (KSAs). In addition to the experience above, the candidate must demonstrate ALL of the following KSAs: (a) Comprehensive knowledge of health record technology methods, procedures, and techniques. (b) Ability to work with a team to provide technical guidance, and to plan, organize, and coordinate activities to effectively complete job assignments (i.e., distributing workload, monitoring the status and progress of work, monitoring accuracy of work, and ensuring required timelines are met.) (c) Skill in communicating effectively, both orally and in writing, to meet program objectives. (d) Ability to prepare reports in a variety of formats and present data to individuals at various organizational levels. (e) Ability to coordinate and provide staff development and training. Assignment. For all assignments above the full performance level, the higher-level duties must consist of significant scope, complexity (difficulty), range of variety, and be performed by the incumbent at least 25% of the time. Lead MRTs HIT perform quantitative and qualitative reviews of health record documentation, initiate various reports, and analyze data. They coordinate, assign, and monitor the workflow. They ensure that team assignments are carried out by distributing and balancing workload, monitoring the status and progress of work, and adjusting workload in accordance with established priorities, instructing and answering employee questions, checking employee work, and amending or rejecting work that does not meet work standards. Lead MRTs HIT train and provide expert advice on specific tasks, procedures, and policies. Lead MRTs HIT are responsible for assisting staff with completing the health record for patient transfers, legal cases, or other urgent requests. They identify and abstract information from health records for internal and external audits and special studies. Reference: For more information on this qualification standard, please visit https://www.va.gov/ohrm/QualificationStandards/. The full performance level of this vacancy is GS-08. Physical Requirements: Have the mental, emotional, and physical ability to satisfactorily perform the duties of the proposed assignment and to pass the requisite laboratory and other screening as required by Federal regulatory agencies.
Functions Performs the quantitative and qualitative analysis on both computer and paper-based health records. Reviews 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. Maintains a control system to ensure completion of all inpatient and outpatient records in accordance with VA, The Joint Commission, CMS, and other regulatory agencies' standards. Identifies health record deficiencies, tracks deficiencies, and ensures that the appropriate individual completes their deficiencies. Assesses the paper health record and electronic Computerized Patient Record System (CPRS) for completeness and notes deficiencies in the tracker on the SharePoint site. Makes appropriate recommendations for changes or solutions and implements appropriate recommendations for corrective action when authorized, so that continued filing errors do not occur. Obtains statistical information, applies statistical formulas, and completes statistical reports for medical center management. Prepares weekly and monthly reports, noting the status of all incomplete/delinquent health records and submitting the reports to the appropriate administrative and clinical staff. Identifies and abstracts information from health records for special studies and audits, both internal and external. Lead Duties: Provides guidance and technical direction necessary for accomplishing the work of the unit or team. Serves as work leader, assuring the work assignments of employees in the unit are carried out. Ensures the organization's "vision" is integrated into the team's goals, strategies, activity plans, and work products. Monitors the status and progress of work and makes adjustments in accordance with established priorities. Maintains records of work accomplishments. Provides expert advice on specific tasks, procedures, and policies. Makes written instructions, reference materials, and relevant background material available. Resolves simple informal complaints of employees and refers more serious matters to the supervisor. Makes recommendations to the supervisor as requested concerning promotions, reassignments, recognition of performance, and personnel needs. Work Schedule: 7:30 am - 4:00 pm, Monday-Friday 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 Financial Disclosure Report: Not required