The Medical Records Technician (Health Information Technician) (MRT(HIT)) at the Lexington VA Medical Center, Pathology and Laboratory Medicine Service, reviews, analyzes, abstracts, maintains, extracts, and compiles information from health record (Anatomic Pathology report) independently with minimal supervision.

Duties

They analyze health records (Anatomic Pathology reports) for accuracy, completeness, timeliness, consistency, and compliance (e.g., scanned, uploaded, use of correct titles, linked to correct encounter, etc.) with Heath Information Management and Pathology and Laboratory Medical Service standards, policies, procedures, laws, regulations, and accreditation requirements. They coordinate and/or perform health record (Anatomic Pathology report) review activities to satisfy external accreditation requirements and medical center performance measures. The MRT HIT communicates regularly with pathologists and staff at various levels of the organization regarding incomplete health records (Anatomic Pathology reports) and notifies pathologists of incomplete health records (Anatomic Pathology reports). They conduct reviews and create reports noting the status of all incomplete/delinquent records and submit reports to the appropriate administrative staff and/or Pathologists to ensure deficiencies are resolved and completed appropriately. The MRT HIT serves as the expert resource for staff and assists pathologists with completion or correction of their health record (Anatomic Pathology report) documentation. The MRT HIT coordinates the use of medical speech recognition/transcription and monitors, verifies, troubleshoots, corrects, and/or uploads all transcription/medical speech recognition to maintain completeness and accuracy of health records (Anatomic Pathology reports. They serve as the technical expert in the health record (Anatomic Pathology report) content and documentation requirements. Duties or Functions of this position include but are not limited to: Utilize transcription software program to transcribe dictations for surgical, cytology and autopsy patient reports. Monitor, troubleshoot, correct and/or upload all transcription/medical speech recognition to ensure complete and accurate surgical, cytology and autopsy patient reports. Ensure all surgical, cytology and autopsy documentation requirements are met for regulatory compliance. Responsible for proper medical terminology, grammar, spelling, punctuation, completeness, and format of surgical, cytology and autopsy patient reports. Work directly with Pathologists to ensure timely and accurate completion of Pathology reports. Organize and maintain draft and final Pathology reports to comply with mandated retention times. Determine and enter correct Current Procedural Terminology (CPT) and Systemized Nomenclature of Medicine (SNOMED) codes into Surgical Pathology final reports with the assistance of the pathologist if needed, to assure facility is reimbursed appropriate revenue per procedure. Receive consult requests from pathologists, retrieve requested pathology slides/blocks for shipment to outside facilities. Ensure pathology materials are sent to correct consulting facility. Receive completed consult reports and include required addendums and or modify original reports to include information from consult report. Utilize CAP website and collaborate with tumor registrar, UKMC, and staff pathologists to ensure current/accurate cancer templates are utilized for patient reports. Ensure pathology slides/blocks sent to outside facilities are documented in Laboratory Disclosure excel spreadsheet for tracking purposes and record of release of personal patient information. Responsible for entering release and return of all original patient pathology slides/blocks. Monitor submission/receipt of cases to outside facilities for consultation. Responsible for investigating delayed or missing reports from outside facilities. Monitor completion status of consults and outside testing reports. Contact outside facilities for any delayed or missing reports to ensure turnaround time requirements are met. Maintain complete consult records for quality assurance. Field and triage requests for molecular testing in Anatomic Pathology. Completes appropriate requisitions with required information. Pulls case history from Vista and retrieves corresponding slides for review by pathologist for send out approval. Utilizes molecular testing portal to enter patient information for test submission. Coordinates specimen pickup and tracks specimens sent for testing to ensure timely completion of results. Scans completed molecular genetics final reports into patient report and ensures the modified report is reviewed and signed again by the appropriate pathologist. Work Schedule: Monday through Friday 8:00 am to 4:30 pm Telework: May be available on an ADHOC basis based on the needs of the Service Virtual: This is not a virtual position. Functional Statement #: GS-4 - 30266-F / GS-5 - 30267-F / GS-6 - 30255-F / GS-7 - 30256-F 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. DEFINITIONS. a. Journey Level. The full performance level for the MRT HIT assignment is GS-07. b. Creditable Experience. Experience is only creditable if it is paid or non-paid employment directly related to the position to be filled, or in a related field, such as medical support assistants, clinic/ward clerks, health record file room/scanning technicians, medical coding, or other positions that include knowledge of the content and uses of health records. To be creditable, the candidate's experience must have demonstrated the use of knowledge, skills, and abilities associated with current MRTHIT practice. c. Quality of Experience. To be creditable, experience must be documented on the application or resume and verified in an employment reference, or through other independent means. d. Part-Time Experience. Part-time experience as a MRT HIT is creditable according to its relationship to the full-time workweek. For example, a MRT HIT would receive one week of full-time credit for each two weeks of half-time work. Basic Requirements: United States Citizenship. Proficient in basic written and spoken English Meet physical requirements. Meet basic education and/or experience. (See Grade Determination below) 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). Grade Determinations: In addition to the basic requirements, the below qualification requirements must be met at the grade(s) in which you are applying. See the application questionnaire for full details of grade qualifications and assignments :https://apply.usastaffing.gov/ViewQuestionnaire/12080212 . GS-04 Entry Level Experience or Education: none beyond the basic education or experience. GS-05 Developmental Level I Experience: One year of experience equivalent to the next lower grade. 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). And 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. GS-06 Experience. One year of experience equivalent to the next lower grade level. And 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. GS-07 (Full Performance Level) Experience. One year of experience equivalent to the next lower grade level. And 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. References: VA Handbook 5005/124, Part II, Appendix G59 The full performance level (Journey Level) of this vacancy is the 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 . Physical Requirements: Position is primarily sedentary in nature with long periods of using computer to perform job functions.

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 Lexington VA Health Care System 2250 Leestown Road Lexington, KY 40511 US
• Name: David Wiseman
• Phone: (614) 935-3242
• Email: [email protected]