This position is in the Health Information Management Section (HIMS) of the Health Administration Service (HAS) Line at VA Puget Sound Health Care System. The duties and responsibilities are carried out throughout both divisions of the medical center. The Medical Record Technician (MRT) is responsible for reviewing, analyzing, organizing, abstracting, processing and maintaining clinical and administrative documents in any medium.

Duties

Duties include, but are not limited to: Applies knowledge of medical terminology, human anatomy/physiology and disease processes to fully understand the content of a patient's medical record. Navigate efficiently through the electronic medical record to find the needed information Understands the internal organization of medical records and medical record references in order to review medical records for presence and timeliness of required documentation. She/he conducts follow-up to ensure completion of necessary documents (e.g., operation reports, discharge summaries, consults, etc.) Abstracts clinical information for ongoing regulatory medical record reviews using VistA TIU, CPRS and IRT software packages. Validates data collected, creates status reports and provides prepared data to HIMS management Coordinates review activities with the Quality Improvement Program to satisfy external accreditation requirements and to satisfy current Medical Center performance measures Reads and abstracts medical and other information from the Computerized Patient Record System (CPRS), VistA Imaging, MUSE and other information from paper medical records Assures that information being reviewed is accurate for medical record completion Works with the Health Information Management team to identify medical record review trends and documentation discrepancies related to review criteria for compliance, regulatory and other oversight (resident supervision, copy and paste, etc) that are required Reviews abstracted information that is from various sources such as photocopied, printed or written to electronic media and/or paper and electronic medical records (e.g.; scanned notes, reports, special tests, etc.). Information will be used for medical record completion to be used by Health Information Management and/or other clinical service lines Tracks incomplete reports for completion using various systems including database and multiple spreadsheet formats Uploads clinical reports directly into VistA/CPRS using the various clinical software packages Organizes workload priorities on a daily basis and coordinate with management within Health Information Management regarding tasks/projects to be completed. Follow-up on pending issues and facilitate work flow processes to ensure work is completed timely and accurately Assists other areas within Health Information Management by using the DSS ROI software to release information to Veterans, outside medical facilities and other areas as requested The duties listed above are for full performance level (GS-7), developmental grade level duties will be of lower complexity and greater supervision. Work Schedule: 8:00 am - 4:30 pm, Monday - Friday Telework: 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

Requirements

• This a Bargaining Unit Position
• You must be a U.S. Citizen to apply for this job
• Designated and/or random drug testing may be required
• Selective Service Registration is required for males born after 12/31/1959
• You may be required to serve a probationary period
• Subject to a background/security investigation
• Must be proficient in written and spoken English
• Selected applicants will be required to complete an online onboarding process

Qualifications

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. 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. Grandfathering Provision. 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. English Language Proficiency: MRTs HIT must be proficient in spoken and written English, as required by 38 U.S.C. ? 7403(f). 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. Grade Determinations: Medical Records Technician (HIT), GS-4 (Entry Level): Experience or Education: None beyond basic requirements. Medical Records Technician (HIT), GS-5 (Developmental Level 1): Experience or Education: One year of experience equivalent to the next lower level (GS-4). OR 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 (KSA's): (a) Ability to communicate effectively with internal and external customers. (b) 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). (c) Knowledge of health record documentation guidelines and industry standards. (d) Ability to manage priorities and coordinate work to complete duties within required timeframes. (e) Ability to apply knowledge of medical terminology and human anatomy to fully understand the content of a health record. Medical Records Technician (HIT), GS-6: Experience: One year of experience equivalent to the next lower grade level (GS-5). AND Demonstrated KSA's: (a) Ability to navigate efficiently through the health record to locate needed information. (b) Ability to analyze health record documentation to ensure compliance with guidelines and industry standards. (c) Skill in investigating potential health record errors and making corrections, when appropriate. (d) Skill in interpreting and applying health information guidelines and using judgment to complete assignments. (e) Ability to follow up on incomplete health record documentation. Medical Records Technician (HIT), GS-7 (Full Performance Level): Experience: One year of experience equivalent to the next lower grade level (GS-6). AND Demonstrated KSA's: (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. References: VA Handbook 5005/124, Part II, Appendix G59, December 10, 2019 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: Moderate lifting (15-44 lbs); use of fingers; use of both hands; walking, standing, repeated bending for 1 hour; ability to see a computer screen; hearing aids are permitted. Environmental factors include working alone or working closely with others.

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 VA Puget Sound Health Care System 1660 South Columbian Way Seattle, WA 98108 US
• Name: Hector Jebulan
• Phone: (253) 582-8440 X75538
• Email: [email protected]