This position is in the Health Information Management (HIM) section at the Jonathan M. Wainwright Memorial VA Medical Center. Health Information Technicians (HITs) review, analyze, abstract, compile, maintain, and extract information from the health record. They also check for completeness and accuracy of the health record and monitor and report for regulatory compliance.

Duties

The nature of the work involves the full scope of review, analysis, monitoring, and follow-up in the Health Information Management Program of the Medical Center. Analytical ability, judgment, discretion and a high level of tact and negotiating are required daily to carry out the functions of this position. Employees at the GS-4 grade level serve in an entry level MRT position and receive close supervision. Employees at the GS-5 and GS-6 grade level serve in developmental positions as MRTs and receive guidance from more experienced staff members for more complex procedures. GS-7 is the full performance level. HIT technicians at this level perform all aspects of the position and help develop lower graded personnel. Roles and responsibilities include: Serve as technical expert in health record content and documentation requirements. Perform quantitative and qualitative reviews of health record documentation. Ensure all patient care data entered into the EHR is accurate, timely, and complete. Adhere to established documentation requirements as outlined by The Joint Commission regulations, Veterans Health Administration (VHA) guidelines, and other medical-legal requirements. Review records for adherence with CMS guidelines related to student, resident supervision and attending physician presence and documentation. Compile reports to ensure provider specific and service compliance. Maintain 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. Review health records to ensure all records contain sufficient information to meet medical/legal requirements, ensure continuity of patient care, and to support education and research needs. Assist clinicians with completion of delinquent/incomplete health records. Perform quantitative and qualitative analysis on both computer and paper-based health records. Consult with the appropriate clinicians for clarification when conflicting or ambiguous information appears in health record documentation. Identify health record deficiencies, track deficiencies, and ensure the appropriate individual completes their deficiencies. Assist physicians complete delinquent/incomplete health records and serve as the expert resource for clinical staff regarding requirements for complete documentation. Expedite 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. Assess paper health records and electronic health records for completeness and notes deficiencies. Track electronic signatures, document deficiencies, and communicate deficiencies to clinical staff for correction. Notification can be in person, internal e-mail, telephone, or through other normal routing system. Work independently to resolve health record deficiency issues, erroneous documents, and corrective action required within Oracle/Cerner and only seek guidance of immediate supervisor and/or Clinical Application Coordinator when issues surface when no precedent or procedure has been developed. Prepare complex weekly and monthly reports noting the status of all incomplete/delinquent records and compliance reports and submit the reports to the appropriate administrative and clinical staff. Perform 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. Identify, review, verify, and correct all statistical data concerning medical transcription to maintain accuracy of medical and statistical reports. Compare and resolve 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. Review health records for adherence with guidelines related to resident supervision and attending physician presence. Work with interdisciplinary staff to solve problems regarding proper health record documentation and completion. Develop and compile written reports trending provider specific, service, and hospital compliance reports regarding admission subsequent and discharge notes. Obtain statistical information, apply statistical formulas, and complete statistical reports for medical center management. Work Schedule: Mon - Fri, 8am to 4:30pm Telework: Not 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

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 and Education. (1) 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 (2) 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 (3) 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. English Language Proficiency. MRTs HIT must be proficient in spoken and written English, as required by 38 U.S.C. ? 7403(f). 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. Medical Records Technician (HIT), GS-4 (Entry Level) Experience or Education. None beyond basic requirements. Medical Records Technician (HIT), GS-5 (Developmental Level 1) (1) Experience. One year of experience equivalent to the next lower level. OR (2) 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. Medical Records Technician (HIT), GS-6 (Developmental Level 2) 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. Medical Records Technician (HIT), GS-7 (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. Preferred Experience: At least 1yr of medical records experience, preferably utilizing Cerner or Genesis electronic health records software/applications. 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: Work requires use of fingers; sitting (up to 8 hours); and computer work (up to 8 hours). Must be able to work alone and 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 Jonathan M Wainwright Memorial VA Medical Center 77 Wainwright Drive Walla Walla, WA 99362 US
• Name: Joe Julkowski
• Phone: 509-434-7382
• Email: [email protected]