This position is located in the Health Administration Service at the Tomah VA Medical Center. MRTs 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.

Duties

Full performance level of a Medical Record Technician (HIT) is a 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. GS-4 Basic Entry Level: Employees at this level serve as entry level MRTs HIT and receive close supervision from the supervisory MRT HIT or designee. MRTs HIT 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. They perform health record review activities to satisfy external accreditation requirements and medical center performance measures. They monitor, verify, correct, and upload all transcription/medical speech recognition to maintain completeness and accuracy of health records. GS-5 Developmental Level 1: 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. MRTs HIT 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. They create and monitor reports to ensure that deficiencies are resolved and completed appropriately. They 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 Development Level 2: 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. They 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. They assist clinical providers regarding completeness of their health record documentation, and the correction of health records. They conduct reviews of incomplete records for individuals clearing the facility. They create and monitor reports to ensure that deficiencies are resolved and completed appropriately. They 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 Full Performance Level 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. Notifies clinical providers regarding incomplete health records. Assist clinical providers regarding completeness of their health record documentation, and the correction of health records. 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. Responsible for performing quantitative and qualitative reviews of health record documentation. Performs the quantitative and qualitative analysis on both computer and paper based health records. Tracks electronic signatures and documents deficiencies and communicates these deficiencies to clinical staff for correction. Identifies reviews, verifies, and corrects all statistical data concerning medical transcription to maintain accuracy of medical and statistical reports. Work Schedule: Full time, Monday - Friday, 8:00am - 4:30pm Telework: Not available Virtual: This is not a virtual position. Relocation/Recruitment Incentives: Not authorized Permanent Change of Station (PCS): Not authorized Financial Disclosure Report: Not required

Requirements

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: The following are the basic requirements and qualifications for this position: English Language Proficiency Basic Experience: One year of creditable experience that indicates knowledge of medical terminology and general understanding of health record. Six months of the required one year of creditable experience must have provided the knowledge, skills and abilities (KSAs) needed to perform MRT 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 Basic Education: An associate 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, legal aspects of health care, and introduction to health records and introduction to health records). Transcripts Required. OR Basic Combination Education and Experience: Equivalent combinations of creditable experience and education are qualifying for meeting the basic requirements. The following education/training substitutions are appropriate for combining education and creditable experience. 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 year above high school with a minimum of 6 semester hours of health information, health technology, or health information management 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 for 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. Grade Determination: In addition to the basic requirements above the following is the amount of creditable experience and/or education required to qualify for this position at the GS-4 through GS-7 grade level. GS-4 Entry Level: None beyond the basic requirements above. GS-5 Developmental Level 1 - Experience or Education: At least 1 year of creditable experience comparable to the next lower grade level (GS-4) or 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 information management (e.g., courses in medical terminology, anatomy and physiology, legal aspects of health care, and introduction to health records). In addition, I can demonstrate the following KSAs: (1) Ability to communicate effectively with internal and external customers. (2) 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). (3) Knowledge of health record documentation guidelines and industry standards. (4) Ability to manage priorities and coordinate work to complete duties within required timeframes. (5) Ability to apply knowledge of medical terminology and human anatomy to fully understand the content of a health record. Transcripts required if qualifying based on Education. GS-6 Development Level 2 Experience: At least one full year of creditable experience as an MRT (HIT) to the next lower level (GS-5) which demonstrates the KSAs related to the duties of the position to be filled. In addition, I can demonstrate the following KSAs: (1) Ability to navigate efficiently through the health record to locate needed information. (2) Ability to analyze health record documentation to ensure compliance with guidelines and industry standards. (3) Skill in investigating potential health record errors and making corrections, when appropriate. (4) Skill in interpreting and applying health information guidelines and using judgment to complete assignments. (5) Ability to follow up on incomplete health record documentation. GS-7 Full Performance Level: At least one full year of creditable experience as an MRT (HIT) to the next lower level (GS-6) which demonstrates the KSAs related to the duties of the position to be filled. In addition, I can demonstrate the following KSAs: (1) 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. (2) Ability to take appropriate actions in health record content is not adequate, accurate, timely and/or reliable. (3) Ability to communicate both orally and in writing with individuals or groups, to facilitate compliance with established policies and regulations. (4) Skill in using appropriate software and computer applications to analyze and record documentation trends. (5) Ability to apply qualitative and/or quantitative methods for assessment and improvement of heath records. (6) Ability to work independently and utilize problem-solving techniques in the accomplishment of work. References: VA Handbook 5005/123, Part II, Appendix G58, Medical Record Technician (Release of Information) Qualification Standards, 12/10/2019. Physical Requirements: The work is sedentary, but may require walking, bending, standing, and /or carrying of light items such as files and manuals. The work does not require any special physical effort or ability. Work Environment: The work area is usually an adequately lighted, heated, and ventilated office or medical facility setting. The work environment involves everyday risks or discomforts that require normal safety precautions.

Education

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: http://www.ed.gov/about/offices/list/ous/international/usnei/us/edlite-visitus-forrecog.html.

Contacts

• Address Tomah VA Medical Center 500 East Veterans Street Tomah, WI 54660 US
• Name: Joseph Tourek
• Email: [email protected]