This position is eligible for the Education Debt Reduction Program (EDRP), a student loan payment reimbursement program. You must meet specific individual eligibility requirements in accordance with VHA policy and submit your EDRP application within four months of appointment. Approval, award amount (up to $200,000) and eligibility period (one to five years) are determined by the VHA Education Loan Repayment Services program office after complete review of the EDRP application.

Duties

This position is located in the Health Information Management (HIM) Section of the Business Operation Service (BOS) at the VA St. Louis Health Care System (VASTLHCS) St. Louis Missouri. The Medical Record Technician (MRT) Health Information Technician (HIT) reviews, analyze, abstract, compile, maintain, and extract information from the health record. Assess for completeness and accuracy of the health record and monitor/report for regulatory compliance. Employees at this grade level are considered the full performance for MRT (HIT) and receive guidance from more experienced HIT staff members for more complex medical records. MRTs HIT perform incomplete health record analysis. Duties include but are not limited to the following: Incumbent serves as technical expert in health record content and documentation requirements. Incumbent is responsible for performing quantitative and qualitative reviews of health record documentation. Incumbent is responsible for ensuring that all patient care data entered in the health record is accurate, timely, and completed. Adhere to established documentation requirements as outlined by The Joint Commission regulations, Veterans Health Administration (VHA) guidelines, as well as medical-legal requirements. Reviews health records for adherence with CMS guidelines related to student, resident supervision and attending physician presence and documentation. Compile reports to insure 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. 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. Identifies inaccurate data and takes necessary corrective action(s). Assist clinicians with completion of delinquent/incomplete health records. The incumbent performs the quantitative and qualitative analysis on both electronic and paper-based health records. Consult with the appropriate clinician(s) for clarification when conflicting or ambiguous information appears in the health record documentation. Identify health record deficiencies, track deficiencies and ensure that the appropriate individual completes their deficiencies. The incumbent assists physicians with the completion of delinquent/incomplete health records and servers 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. Assess the paper health record and CPRS for completeness and note deficiencies in the Incomplete Record Tracking System, Nuance, etc. Track electronic signatures and document deficiencies and communicate these deficiencies to clinical staff for correction. Notification can be in person, internal e-mail, telephone, or through other normal routing system. Work independently resolving record deficiency issues/erroneous documents. Initiate corrective action in CPRS and only seek guidance 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; 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 identifying the correct patient with the associated report. Assign/file the report correctly. Duties include the generation of various statistical reports to track these errors. Make appropriate recommendation for changes or solutions and facilitate for corrective action when authorized to eliminate filing errors. 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. The full performance level for the MRT HIT assignment is GS-7. Work Schedule: Monday - Friday 7:00am - 3:30pm Telework: Available (Ad-hoc) Virtual: This is not a virtual position. Functional Statement #: 000000 EDRP Authorized: Contact [email protected], the EDRP Coordinator for questions/assistance. Learn more 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: United States Citizenship: Citizen of the United States. (Non-citizens may be appointed when it is not possible to recruit qualified citizens in accordance with chapter 3, section A, paragraph 3g, this part.) 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. 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. a. Physical Requirements. See VA Directive and Handbook 5019, Employee Occupational Health Service. b. English Language Proficiency. MRTs HIT must be proficient in spoken and written English, as required by 38 U.S.C. ? 7403(f). Grade Determinations: 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 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. Physical Requirements: The work is sedentary. Typically, the employee sits comfortably to do the work. However, there may be some walking; standing; bending; carrying of light items such as papers, books, small part; or driving an automobile, etc. No special physical demands are required to perform the work.

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 St Louis Health Care System 1 Jefferson Barracks Drive St. Louis, MO 63125 US
• Name: Leslie Doyle
• Phone: 9284454860 X6968
• Email: [email protected]