This position is located in the Health Information Management Service at the James A. Haley Veterans' Hospital and Clinics. This position supports the Electronic Medical Record including coordination of resolution for all issues with wrong notes, Medical Record Review Committee, and notification to clinicians for records to complete. The Document Specialist is the critical and final checkpoint to ensure completeness of the record.

Duties

Preferred experience: Experience navigating CPRS. Assignment This is considered the journey level for MRTs HIT. MRTs HIT at this level review, analyze, abstract, maintain, extract, and compile information from the health record independently with minimal supervision. They analyze health records for accuracy, completeness, timeliness, consistency, and compliance (e.g., scanned, uploaded, use of correct titles, linked to correct encounters, etc.) with HIM industry standards, policies, procedures, laws, regulations, and accreditation requirements. They also coordinate and/or perform health record review activities to satisfy external accreditation requirements and medical center performance measures. They communicate regularly with staff at various levels of the organization regarding delinquent health records and notify individual clinical providers regarding incomplete medical records. MRTs HIT prepare complex reports, calculate department statistics, note the status of all incomplete/delinquent records, and submit reports to the appropriate administrative and clinical staff and committees/leadership to ensure deficiencies are resolved and completed appropriately. They serve as the expert resource for clinical staff and assist clinical providers with completion or correction of their health record documentation. They conduct the review of incomplete records for individuals clearing the facility. MRTs HIT coordinate the use of medical speech recognition/transcription and monitor, verify, troubleshoot, correct, and/or upload all transcription/medical speech recognition to maintain completeness and accuracy of health records. They serve as the technical expert in health record content and documentation requirements. Demonstrated 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. (f) Ability to work independently and utilize problem-solving techniques in the accomplishment of work. 5. Customer Service Requirements- Relationships with management, co-workers, patients, and the general public are consistently courteous, respectful, and cooperative in nature. Incumbent will display a cooperative attitude and will effectively work together to implement the organization's mission and goals. Incumbent will ensure productivity is maintained at the established level for the program for which he/she is responsible. Work Schedule: Monday - Friday 7:30am to 4pm Compressed/Flexible:no Telework: yes Virtual: This is not a virtual position. 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
• Designated and/or random drug testing may be required
• Selective Service Registration is required for males born after 12/31/1959
• You may be required to serve a probationary period
• Subject to a background/security investigation
• Must be proficient in written and spoken English
• Selected applicants will be required to complete an online onboarding process

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. 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 for meeting the basic 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. English Language Proficiency. MRTs HIT must be proficient in spoken and written English, as required by 38 U.S.C. § 7403(f) Physical Requirements: See VA Directive and Handbook 5019, Employee Occupational Health Service. 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 Record Technician (Health Information Technician - HIT) Medical Records Technician (HIT), GS-7 (Full Performance Level) (a) Experience. One year of creditable experience equivalent to the next lower grade level (GS-6). Examples of specialized experience include, but are not limited to, the following: Analyze, abstract, maintain, extract, and compile information from the health record independently with minimal supervision; analyze health records for accuracy, completeness, timeliness, consistency, and compliance (e.g., scanned, uploaded, use of correct titles, linked to correct encounters, etc.), with HIM industry standards, policies, procedures, laws, regulations, and accrediting bodies. They perform health record review activities to satisfy external accreditation requirements and medical center performance measures. They monitor, verify, correct, and upload all transcription/medical speech recognition to maintain completeness and accuracy of health records. (b) Assignment. This is considered the journey level for MRTs HIT. MRTs HIT at this level review, analyze, abstract, maintain, extract, and compile information from the health record independently with minimal supervision. (c) Demonstrated Knowledge, Skills, and Abilities. (For full qualification standard please reference the VA Handbook 5005/124, Part II Appendix G59, Medical Record Technician Qualification Standard below) References: VA Handbook 5005/124 Part II, Appendix G-59, Medical Record Technician Qualification Standard. The full performance level (FPL) of this vacancy is GS-7.

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: https://sites.ed.gov/international/recognition-of-foreign-qualifications/.

Contacts

• Address James A Haley Veterans Hospital 13000 Bruce B. Downs Boulevard Tampa, FL 33612 US
• Name: Karen McKee
• Phone: 352-548-6000 X105242
• Email: [email protected]