MEDICAL RECORDS TECH (HEALTH INFORMATION TECHNICIAN) in Hampton, Virginia

Summary This position is located in the Health Information Management (HIM) section of the Health Administration Service (HAS) at the Hampton VA Medical Center. The incumbent performs incomplete health record analysis. They review, analyze, abstract, maintain, extract, and compile information from the health record. The incumbent checks for accuracy, completeness, and timeliness of the health record and monitor and report for regulatory compliance. Responsibilities Assignments/duties for each grade level are listed below but not all inclusive: GS-4: Employees at this level serve as entry level MRTs HIT, and receive close supervision from the supervisory MRT HIT or designee. 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 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. GS-5: Employees at this grade level serve in developmental positions as MRTs HIT. Employees receive guidance from the supervisory MRT HIT, or designee, for more complex health record reviews. 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 requirement. They perform health record review activities to satisfy external accreditation requirements and medical center performance measures. 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. MRTs HIT notify clinical providers regarding incomplete health records, and assist clinical providers regarding completeness of their health record documentation. GS-6: This is a developmental level for MRT HIT. The MRT HIT at this level receives guidance from the supervisory MRT HIT, or designee, for more complex health records. The MRT HIT analyzes, abstracts, maintains, extracts and compiles information from the health record, working under the review of the supervisor. 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. Coordinate and/or perform health record review activities to satisfy external accreditation requirements and medical center performance measures. The MRT HIT 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. 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. MRTs HIT serve as the technical experts in health record content and documentation requirements. GS-7: MRTs HIT at this level review, analyze, abstract, maintain, extract, and compile information from the health record independently with minimal supervision. 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. Coordinate and/or perform health record review activities to satisfy external accreditation requirements and medical center performance measures. Communicate regularly with staff at various levels of the organization regarding delinquent health records, and notify individual clinical providers regarding incomplete medical records. 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. Serve as the expert resource for clinical staff and assist clinical providers with completion or correction of their health record documentation. 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 completeness and accuracy of health records. Serve as the technical expert in health record content and documentation requirements. Work Schedule:7:30am-4pm; 8am-4:30pm Telework: Available, NOTE: This is not a remote position Virtual: This is not a virtual position. Functional Statement #: 000000 Relocation/Recruitment Incentives: Not authorized Permanent Change of Station (PCS): Not authorized Requirements Conditions of Employment You must be a U.S. Citizen to apply for this job. Selective Service Registration is required for males born after 12/31/1959. Must be proficient in written and spoken English. You may be required to serve a probationary period. Subject to background/security investigation. Selected applicants will be required to complete an online onboarding process. Participation in the seasonal influenza vaccination program is a requirement for all Department of Veterans Affairs Health Care Personnel (HCP). Participation in the Coronavirus Disease 2019 (COVID-19) vaccination program is a requirement for all Veterans Health Administration Health Care Personnel (HCP) – See “Additional Information” below for details. 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: Proficient in spoken and written English as required by 38 USC 7403 (f). 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 MRT 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). All persons employed in VHA as a MRT HIT, on the effective date of this qualification standard, 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. For employees who do not meet all the basic requirements in this standard, but who met the qualifications applicable to the position at the time they were appointed to it, the following provisions apply: (1) Such employees in an occupation that does not require a licensure/certification/ registration, may be reassigned, promoted, or demoted within the occupation, but will not be promoted beyond the journey level or placed in supervisory or managerial positions. (2) Employees appointed on a temporary basis prior to the effective date of the qualification standard may not have their temporary appointment extended, or be reappointed on a temporary or permanent basis, until they fully meet the basic requirements of the standard. (3) Employees initially grandfathered into this occupation, who subsequently obtain additional education and/or licensure/certification/registration that meet all the basic requirements of this qualification standard, must maintain the required credentials, as a condition of employment in the occupation. Grade Determinations: In addition to the Basic Requirements above, candidates must also meet any additional requirements to include KSAs based on grade assignment below. Medical Records Tech (Health Information Tech), GS-4 Experience or Education. None beyond basic requirements. Medical Records Tech (Health Information Tech), GS-5 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 (KSAs). In addition to the experience or education 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 Tech (Health Information Tech), GS-6 Experience. One year of experience equivalent to the next lower grade level. Demonstrated Knowledge, Skills and Abilities (KSAs). 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 judgment to complete assignments. Ability to follow up on incomplete health record documentation. Medical Records Tech (Health Information Tech), GS-7 Experience. One year of experience equivalent to the next lower grade level. Demonstrated Knowledge, Skills and Abilities (KSAs). 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. 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-7. The actual grade at which an applicant may be selected for this vacancy is in the range of GS-4 to GS-7. Education Physical Requirements: The position requires occasional, standing, crouching, carrying, stooping, kneeling, pushing and pulling less than 25 pounds. There may be frequent reaching and walking. As this is a sedentary position, it may require sitting for long periods. The incumbent will frequently communicate with staff and customers online, in person and through emails. IMPORTANT: A transcript must be submitted with your application if you are basing all or part of your qualifications on education. Note: Only education or degrees recognized by the U.S. Department of Education from accredited colleges, universities, schools, or institutions may be used to qualify for Federal employment. You can verify your education here: http://ope.ed.gov/accreditation/. If you are using foreign education to meet qualification requirements, you must send a Certificate of Foreign Equivalency with your transcript in order to receive credit for that education. For further information, visit: https://sites.ed.gov/international/recognition-of-foreign-qualifications/. Additional Information During the application process you may have an option to opt-in to make your resume available to hiring managers in the agency who have similar positions. Opting in does not impact your application for this announcement, nor does it guarantee further consideration for additional positions. This job opportunity announcement may be used to fill additional vacancies. This position is in the Excepted Service and does not confer competitive status. VA encourages persons with disabilities to apply. The health-related positions in VA are covered by Title 38, and are not covered by the Schedule A excepted appointment authority. Pursuant to VHA Directive 1193.01, VHA health care personnel (HCP) are required to be fully vaccinated against COVID-19 subject to such accommodations as required by law (i.e., medical, religious or pregnancy). VHA HCPs do not include remote workers who only infrequently enter VHA locations. If selected, you will be required to be fully vaccinated against COVID-19 and submit documentation of proof of vaccination before your start date. The agency will provide additional information regarding what information or documentation will be needed and how you can request a legally required accommodation from this requirement using the reasonable accommodation process. If you are unable to apply online or need an alternate method to submit documents, please reach out to the Agency Contact listed in this Job Opportunity Announcement. Under the Fair Chance to Compete Act, the Department of Veterans Affairs prohibits requesting an applicant’s criminal history prior to accepting a tentative job offer. For more information about the Act and the complaint process, visit Human Resources and Administration/Operations, Security, and Preparedness (HRA/OSP) at The Fair Chance Act.