This position is located in the Health Information Management (HIM) section under the Health Administration Service Line at the Butler 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

Work Schedule: Monday - Friday 7:30 am - 4:00 pm Major Duties: Prepares lists of paper health records needed for signature(s) that are in the incomplete record area for distribution to appropriate service lines (i.e., Medicine, Surgery, Psychiatry, etc.) or that are not complete in the electronic health record. 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. Monitors house staff rotation schedule and contacts resident house staff to insure completion of records prior to departure from the Medical Center if applicable. 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 (PTF) . Conducts periodic audit of records processing activities. Participates in approved quality improvement focused reviews. 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 too and filing/assigning it correctly. Makes appropriate recommendations for changes or solutions and facilitate appropriate recommendations for corrective action when authorized so continued filing errors do not occur. Identifies reviews, verifies, and corrects all statistical data concerning medical transcription to maintain accuracy of medical and statistical reports. Compares and resolves discrepancies between daily Gains and Losses Sheet, Digital System Workload Report, and contract transcription logs as it relates to timeliness and accuracy of dictated reports completed by medical transcription contractor. 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 delinquent/incomplete health records. Consults with the appropriate clinician(s) for clarification when conflicting or ambiguous information appears in the health record documentation. Brings questions regarding conflicting or unclear documentation to the (insert position title) prior to consulting with the clinician. Identifies health record deficiencies, tracks deficiencies, and ensures that the appropriate individual completes their deficiencies. Assists physicians with the completion of delinquent/incomplete health records and servers as the expert resource for clinical staff regarding requirements for complete documentation. Assesses the paper health record and electronic Computerized Patient Record System (CPRS) for completeness and notes deficiencies in the (insert name of record deficiency monitoring system such as IRT, Nuance, etc.). Compressed/Flexible: Not Authorized Telework: Yes. Virtual: This is not a virtual position. Functional Statement #: 0000 Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized Financial Disclosure Report: Not required

Requirements

• You must be a U.S. Citizen to apply for this job.
• All applicants tentatively selected for VA employment in a testing designated position are subject to urinalysis to screen for illegal drug use prior to appointment. Applicants who refuse to be tested will be denied employment with VA.
• Selective Service Registration is required for males born after 12/31/1959.
• Must be proficient in written and spoken English.
• You may be required to serve a probationary period.
• Subject to background/security investigation.
• Selected applicants will be required to complete an online onboarding process.
• Must pass pre-employment physical examination.
• Participation in the seasonal influenza vaccination program is a requirement for all Department of Veterans Affairs Health Care Personnel (HCP).
• Participation in the Coronavirus Disease 2019 (COVID-19) vaccination program is a requirement for all Veterans Health Administration Health Care Personnel (HCP) - See "Additional Information" below for details.

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: United States Citizenship: Non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy. 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). 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: GS-05 Medical Records Technician (HIT) (Developmental Level 1) - Experience/Education Requirement: In addition to meeting the basic requirements, to qualify for the GS-05 must have one year of experience equivalent to theGS-04 grade level. OR Education: Must have 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). Do you meet one of the below options which demonstrates the following Knowledge, Skills and Abilities? Ability to communicate effectively with internal and external customers. 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). Knowledge of health record documentation guidelines and industry standards. Ability to manage priorities and coordinate work to complete duties within required timeframes. Ability to apply knowledge of medical terminology and human anatomy to fully understand the content of a health record. GS-06 Medical Records Technician (HIT): Experience Requirement: In addition to meeting the basic requirements, to qualify for the GS-06 do you possess at least 1 year of experience equivalent to the GS-05 grade level. Do you meet one of the below options which demonstrates the following Knowledge, Skills and Abilities? Ability to navigate efficiently through the health record to locate needed information. Ability to analyze health record documentation to ensure compliance with guidelines and industry standards. Skill in investigating potential health record errors and making corrections, when appropriate. Skill in interpreting and applying health information guidelines and using judgment to complete assignments. Ability to follow up on incomplete health record documentation. GS-07 Medical Records Technician (HIT) (Full Performance Level): Experience Requirement: In addition to meeting the basic requirements, to qualify for the GS-07 do you possess at least 1 year of experience equivalent to the GS-06 grade level. Do you meet one of the below options which demonstrates the following Knowledge, Skills and Abilities? 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. Ability to take appropriate actions if health record content is not adequate, accurate, timely, and/or reliable. Ability to communicate both orally and in writing with individuals or groups, to facilitate compliance with established policies and regulations. Skill in using appropriate software and computer applications to analyze and record documentation trends. Ability to apply qualitative and/or quantitative methods for assessment and improvement of health records. Ability to work independently and utilize problem-solving techniques in the accomplishment of work. References: VA Handbook 5005/124 Part II G59 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-05, GS-06 and GS-07. Physical Requirements: See VA Directive and Handbook 5019, Employee Occupational Health Service.

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 Butler Healthcare 353 North Duffy Road Butler, PA 16001 US
• Name: Maurice Covington
• Phone: (412) 822-3542
• Email: [email protected]