This position is located in the Health Information Management (HIM) section at the VA Northern California Medical Center. The Medical Record Technician (MRT) in the Release of Information (ROI) section reviews and processes requests for patient protected health information (PHI).

Duties

The duties in this position are primarily advisory and technical in nature. The medical records technician in the release of information section is able to apply, interpret, and analyze laws and regulations related to the disclosure of health information. MRTs (ROI) are responsible for educating requestors on requirements for submitting requests for health information. Major duties include but are not limited to the following: Evaluates the adequacy of each completed authorization form for release of medical records; Accessing and release of medical records in a highly complex, multispecialty acute care hospital; Providing high levels of customer service to Veterans and other stakeholder in person, by phone, or other approved medium; Working in a busy and diverse office environment with requirements to multitask and prioritize duties effectively including appropriate elevation of issues; Abstracts and processes medical releases' of authorizations to release medical information with valid requests that pertain to the Privacy Act, the Freedom of Information Act and Health Insurance Portability and Accountability Act; requests for information from patient's medical records for release to appropriate facility, agency or physician; Reviews paper and computerized medical records (i.e., scanned notes, reports, special tests, etc.) to identify material to be photocopied/printed/written to electronic media and release; Completes and processes routine releases of information to other VA and Federal Agencies and when requested, to patients and their families, insurance representatives, physicians, hospitals, and city and state health agencies according to VA directives. Medical records requests are downloaded and formatted to a CD from multiple computer systems; Composes and types all forms of correspondence to insurance companies, veterans, health care facilities, and other requestors; Screens each request for information to determine urgency and assures that most urgent requests are completed fist using established priority systems; Assists Veterans/visitors in determining the exact nature of the request and whether the information requested can be released; Applies public laws, rules, regulations and exclusions governing confidentiality of the medical record, including the Privacy Act, Freedom of Information Act and 38 U.S.C. 7332 governing the release of records containing information Processes all incoming requests to the facility for Release of Information (ROI) along with information required by the VA Regional Office; Evaluates validity of each request and determines which information is to be released in compliance with existing laws; Ensures that proper authorization exists before release is made and processes the request to the requesting agency or individual; Inputs all requests for logging and tracking; Receives and/or gives out forms, and assists visitors and/or callers with the completion of forms or documents and responds to questions from patients concerning services; Searches records or files to compose responses, including electronic searches to retrieve and summarize hard-to-locate data; Reviews paper and computerized health records (i.e., scanned notes, reports, special tests, etc.) to identify material to be photocopied/printed/written to electronic media and released; Employee composes responses to routine requests for release of patient information; Selects and compiles information from health records and prepares correspondence, typically using standard form or standard formats for letters; Ensures the information released is limited to what is specifically authorized; Processes Social Security requests for health information using ROI software; Completes and processes routine releases of information to other VA and Federal Agencies and when requested, to patients and their families, insurance representatives, physicians, hospitals, and city and state health agencies according to VA directives; Processes requests within established time standards. Work Schedule: Monday through Friday 8:00 AM to 4:30 PM Telework: Not eligible 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

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: Experience. One year of creditable experience that indicates knowledge of medical terminology and 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 (ROI) 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 and 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 experience and educational /training substitutions are appropriate for combining education and creditable experience: 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. The training program may be substituted on a month for-month basis for up to six months of experience provided the training program included courses in anatomy and physiology, and health record techniques and procedures. 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 courses. Grandfathering Provision. All persons employed in VHA as a MRT (ROI) 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. 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 who are 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. Physical Requirements. TB/Immunization Assessment will be conducted by Employee Occupational Health Service. English Language Proficiency. Medical Records Technicians (ROI) must be proficient in spoken and written English, as required by 38 U.S.C. 7403(f). GRADE DETERMINATIONS Medical Records Technician (ROI), GS-4 Experience. None beyond basic requirements. Medical Records Technician (ROI), GS-5 Experience. One year of creditable experience equivalent to the next lower grade level GS-4.OR,Education. 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). Demonstrated Knowledge, Skills, and Abilities. In addition to the experience above, the candidate must demonstrate all of the following KSAs: Ability to utilize health information technology and various office software products utilized in MRT (ROI) positions (e.g., the electronic health record, release of information systems, etc.). Knowledge of health record documentation guidelines and processes for disclosing protected health information. Ability to manage priorities and coordinate work in order to complete duties within required timeframes, and the ability to follow-up on pending issues. Knowledge of policies, procedures, laws, and regulations governing privacy and release of information. Ability to communicate with individuals from various backgrounds to obtain the desired effect or gaining information by establishing rapport. Medical Records Technician (ROI), GS-6 Experience. One year of creditable experience equivalent to the next lower grade level GS-5. 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, ward clerks, health record file room/scanning technicians, incomplete health record analysis, medical coding, or other positions that included knowledge of the content and use of health records. To be creditable, the candidate's experience must demonstrate the use of knowledge, skills, and abilities associated with current release of information practice. Demonstrated Knowledge, Skills, and Abilities. In addition to the experience above, the candidate must demonstrate all of the following KSAs: Knowledge of the laws and regulations related to the authorization and disclosure of health information (e.g., Privacy Act, Freedom of Information Act, Health Insurance Portability and Accountability Act (HIPAA), and 38 U.S.C. 7332, Confidentiality of Certain Medical Records). Ability to apply health record documentation guidelines and processes to navigate efficiently through the paper and/or electronic health record to locate, assemble, and disclose protected health information. Ability to apply policies, procedures, laws, and regulations governing privacy and release of information to process requests for release of information. Ability to research and solve difficult questions related to release of health information in an accurate and timely manner. References: VA Handbook 5005/123, Part II, Appendix G58, December 10, 2019 The full performance level of this vacancy is GS-06. Selection can be from entry level GS-4 to GS-6. Physical Demands: The work involved in this position is mostly sedentary, with long periods sitting at computer desk. Some walking and long periods of standing may be required.

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 Northern California Health Care System 10535 Hospital Way Mather, CA 95655 US
• Name: Marisella Souza
• Phone: 925-356-4088
• Email: [email protected]