The Medical Record Technician (MRT) - Health Information Technician (HIT) performs 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

Some of the duties, roles, and responsibilities of the Lead MRT HIT 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 in VistA and/or Computerized Patient Record System (CPRS) 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. Review 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. 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 the health record documentation. Identify health record deficiencies, track deficiencies, and ensure the appropriate individual completes their deficiencies. Assist physicians with completion of 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 agency review, and reimbursement purposes. Assess paper health record and electronic Computerized Patient Record System (CPRS) for completeness and note deficiencies. Track electronic signatures, document deficiencies, and communicate the deficiencies to clinical staff for correction. Notification can be in person, internal e-mail, telephone, or through other normal routing system. 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. Preform 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. Make appropriate recommendations for changes or solutions and implement appropriate recommendations for corrective action when authorized so continued filing errors do not occur. 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 record 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. Obtain statistical information, apply statistical formulas, and complete statistical reports for medical center management. Participate in routine and focused reviews to identify problems and potential problems in health record documentation as part of the health record review process. Perform lead functions over MRT (HIT) positions and provide guidance and technical direction necessary for accomplishing the work of the unit or team. Serve as work leader, assuring work assignments of employees in the unit are carried out. Distribute and balance workload and tasks among employees. Communicate the problem to be solved or program issues under review and coach the team and/or individual team members in identifying the parameters of a viable solution. Ensure the organization's "vision" is integrated into team goals, strategies, activity plans, and work products. Ensure team members participate in both short-term and long-term planning stages of team projects. Maintain knowledge and answer questions from team members on procedures, policies, and directives. Obtain needed information on decisions from the supervisor on major issues and problems that arise. Resolve simple informal complaints of employees and refer more serious matters to the supervisor. Make recommendations to supervisor as requested concerning promotions, reassignments, and recognition of performance. Work Schedule: Mon - Fri, 8:00am to 4:30pm Telework: 100% but must live within commuting distance of Spokane, WA. 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). GRADE DETERMINATIONS. Lead Medical Records Technician (HIT), GS-8 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) Comprehensive knowledge of health record technology methods, procedures, and techniques. (b) Ability to work with a team to provide technical guidance, and to plan, organize, and coordinate activities to effectively complete job assignments (i.e., distributing workload, monitoring the status and progress of work, monitoring accuracy of work, and ensuring required timelines are met.) (c) Skill in communicating effectively, both orally and in writing, to meet program objectives. (d) Ability to prepare reports in a variety of formats and present data to individuals at various organizational levels. (e) Ability to coordinate and provide staff development and training. 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-8. Physical Requirements: 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: https://sites.ed.gov/international/recognition-of-foreign-qualifications/.

Contacts

• Address Mann-Grandstaff Department of Veterans Affairs Medical Center 4815 North Assembly Street Spokane, WA 99205 US
• Name: Joe Julkowski
• Phone: 509-434-7382
• Email: [email protected]