This position is located in the Health Information Management (HIM) Section at the Fayetteville NC VA Coastal Health Care System. Health Information Technicians (HITs) review, analyze, abstract, compile, maintain, and extract information from the health record. They also check for completeness, timeliness and accuracy of the health record, and monitor and report for regulatory compliance.

Duties

GS-04 Contacts physicians and other ancillary service personnel regarding dictation and/or signatures. Assists medical staff by providing information as to required documentation. Communicates very closely with the medical staff to answer questions and resolve problems to insure quality documentation in the health records. Monitors delinquent dictation list for follow-up purposes on necessary documents that are needed for completion of health records. Monitors house staff rotation schedule and contacts resident house staff to ensure completion of records prior to departure from the Medical Center. Utilizes basic knowledge of medical terminology, anatomy and physiology, and coding to research and collect information for various medical studies and research projects utilizing the Patient Treatment File. GS-05 Contacts physicians and other ancillary service personnel regarding dictation and/or signatures. Assists medical staff by providing information as to required documentation. Communicates very closely with the medical staff to answer questions and resolve problems to insure quality documentation in the health records. Monitors delinquent dictation list for follow-up purposes on necessary documents (i.e., operation reports, discharge summaries, etc.) that are needed for completion of health records. Notifies appropriate physician and other personnel of the status of dictation. Coordinates review activities with the Quality Improvement Program to satisfy external accreditation requirements, and to satisfy current Medical Center performance measures. Assists with capture and reporting of health record documentation deficiencies as needed including downloading data and creating trended reports. Preforms analytical tasks associated with the resolution of "filing" errors on reports uploaded by a transcription vendor. This includes correctly identifying the patient the report belongs to and filing/assigning it correctly. Identifies reviews, verifies, and corrects all statistical data concerning medical transcription to maintain accuracy of medical and statistical reports. GS-06 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. Assists clinicians with completion of incomplete/delinquent health records. Consults with the appropriate clinician(s) for clarification when conflicting or ambiguous information appears in the health record documentation. Identifies health record deficiencies, tracks deficiencies and ensures that the appropriate individual completes their deficiencies. Tracks electronic signatures and documents deficiencies and communicates these deficiencies to clinical staff for correction. Works independently resolving record deficiency issues/erroneous documents and corrective action required within CPRS. Prepares complex weekly and monthly reports noting the status of all incomplete/delinquent records and compliance reports and submits the reports to the appropriate administrative and clinical staff. Identifies reviews, verifies, and corrects all statistical data concerning medical transcription to maintain accuracy of medical and statistical reports. GS-07 Reviews records for adherence with CMS guidelines related to student, resident supervision and attending physician presence and documentation. 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. 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. Consults with the appropriate clinician(s) for clarification when conflicting or ambiguous information appears in the health record documentation. Identifies health record deficiencies, tracks deficiencies and ensures that the appropriate individual completes their deficiencies. The incumbent assists physicians with the completion of incomplete/delinquent health records and serves as the expert resource for clinical staff regarding requirements for complete documentation. Responsible for expediting the completion of the health record when the patient is transferred for care at another medical center, for legal requests, regulatory agencies review, and reimbursement purposes. Assesses the Computerized Patient Record System (CPRS) for completeness and notes deficiencies for reporting. Tracks electronic signatures and documents deficiencies and communicates these deficiencies to clinical staff for correction. Prepares complex weekly and monthly reports noting the status of all incomplete/delinquent records and compliance reports and submits the reports to the appropriate administrative and clinical staff. Work Schedule: Monday-Friday, 0800-1630

Requirements

Qualifications

Basic Requirements: United States Citizenship: Citizen of the United States. ( 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, as required by 38 U.S.C. ? 7403(f). 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. Medical Records Technician (HIT), GS-4 (Entry Level) (1) Experience or Education. None beyond basic requirements. Assignment. 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. Medical Records Technician (HIT), GS-5 (Developmental Level 1) (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). Assignment. 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. Demonstrated Knowledge, Skills, and Abilities. In addition to the experience above, the candidate must demonstrate all of the following KSAs: (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(1) Experience. One year of experience equivalent to the next lower grade level.(2) Assignment. 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. Demonstrated Knowledge, Skills, and Abilities. In addition to the experience above, the candidate must demonstrate all of the following KSAs: (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)(1) Experience. One year of experience equivalent to the next lower grade level.(2) 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. (3) Demonstrated Knowledge, Skills, and Abilities. In addition to the experience above, the candidate must demonstrate all of the following KSAs:(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. Preferred Experience: One year of experience that indicates knowledge of medical terminology and a general understanding of the health record. Knowledge of qualitative and and/or quantitative methods for assessment and improvement of medical record functions. References: The full performance level of this vacancy is GS-07. The actual grade at which an applicant may be selected for this vacancy is in the range of GS-04 to GS-07.

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 Fayetteville NC VA Medical Center 2300 Ramsey Street Fayetteville, NC 28301 US
• Name: Kyndle Taylor
• Phone: 910-488-2120
• Email: [email protected]