The Medical Records Technician- Health Information Technician (HIT) collects, analyzes, reports, and presents data from the medical record to meet several health information duties: provider credentialing and privileging, and academic requirements. This position also conducts special projects for Programs offered within the Education Service under the supervision of the Health System Specialist and guidance of the Associate Chief of Staff for Education (ACOS/E).

Duties

Duties include but are not limited to: Performs concurrent and ongoing medical record documentation review of the patient chart for data collection and reporting in accordance with Joint Commission standards, VHA directives, and local policies. Assists with monitoring and reporting to improve and enhance the quality and safety of patient care and to support the medical center's educational environment, culture of learning, and patient safety. Reviews charts, monitoring, and reporting activities for various programs which includes but is not limited to Resident Supervision, Associated Health Supervision, copy and paste, unapproved abbreviations, and provider specific credentialing and privileging renewal requirements for Ongoing Professional Practice Evaluation (OPPE). Reviews and analyzes medical record to identify and report documentation that is not in compliance with established policies, standards, and regulations for the purpose of appropriate reporting and action by the supervising practitioner or committee. Obtains relevant and accurate patient record data, organizes, files, and retrieves reports, correspondence, and numerical data for the preparation of reports, briefings, and presentations. Reviews analysis of work processes or service delivery practices to identify reasonable and efficient measurement of the quality of the work or the activity and to identify areas of possible improvement as it relates to medical record documentation. Updates the quantitative and qualitative analysis on medical records to ensure that all component parts are present, accurate, complete, timely, and will meet the established requirements and standards of VHA Directives, policy, and medical staff bylaws. Develops, produces, and distributes reports and data analysis to leadership, clinicians, and program administrators for use in decision making regarding medical record documentation, quality assurance, and performance improvement. Uses knowledge of an extensive body of VHA and VALLHCS, Accreditation Council for Graduate Medical Education and The Joint Commission technical rules, guidelines, regulations, and knowledge of the basic objectives and policies governing various management or program operations. Assesses compliance with regulation and accreditation standards. Knowledge of professional practice standards across all specialties of the healthcare system to review the medical record and contribute to the evaluations for Ongoing Provider Proactive Evaluation (OPPE). Uses the Computerized Patient Record System, electronic databases, office automation software and other specialty software systems for inputting, presentation and reporting of data for analysis. Interprets VA regulations, directives, and HCS policies and procedures as they apply to clinical care, documentation requirements, trainee supervision, and medical staff requirements. Interprets, applies, and reports deficiencies of medical record documentation as required by the regulations, guidelines, and policies. Analyzes policy, regulation, and corresponding data to make informed recommendations and reports for leadership to develop realistic improvement plans for related programs. Conducts complex analytical studies regarding the appropriateness and documentation of patient care documentation in accordance with medical staff bylaws, professional practice standards, and academic regulation. Researches the entire medical record and understands the processes and terminology to identify all clinical information and to verify that it contains appropriate documentation for the purposes of the specific review and report. Analyzes and evaluates the issues involved with each assignment, selects, and applies appropriate guidelines and standard techniques and procedures; and decides on a course of action from many alternatives. Demonstrates integrity and good judgment in safeguarding security of information. Work Schedule: Full-Time, Monday-Friday 8:00am-4:30pm Telework: 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

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. English Language Proficiency: MRTs HIT must be proficient in spoken and written English, as required by 38 U.S.C. § 7403(f). Experience and Education: 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, 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, 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: 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. 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. 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-4 Medical Records Technician (HIT), (Entry Level) Experience or Education. None beyond basic requirements. GS-5 Medical Records Technician (HIT) (Developmental Level 1) Experience. One year of experience equivalent to the next lower level. 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). Demonstrated Knowledge, Skills, and Abilities. In addition to the experience above, the candidate must demonstrate all of the following KSAs: 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-6 Medical Records Technician (HIT) Experience. One year of experience equivalent to the next lower grade level. Demonstrated Knowledge, Skills, and Abilities. In addition to the experience above, the candidate must demonstrate all of the following KSAs: 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-7 Medical Records Technician (HIT) (Full Performance Level) Experience. One year of experience equivalent to the next lower grade level. Demonstrated Knowledge, Skills, and Abilities. In addition to the experience above, the candidate must demonstrate all of the following KSAs: 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. Preferred Experience: 1-3 years as an MRT within the VA. References: VA Handbook 5005/124, PART II, APPENDIX G59 Medical Records Technician (Health Information Technician) Qualification Standard GS-0675 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: Light lifting, under 15 lbs., moderate carrying, 15-44 lbs., reaching above shoulder, use of fingers, standing 4-6 hours; hearing, aid permitted. Duties require extensive use of fingers to perform keyboarding and the ability to hear requests by phone and in person. Version must be adequate to read and prepare documents.

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 Jerry L Pettis Memorial Veterans Hospital 11201 Benton Street Loma Linda, CA 92357 US
• Name: Christina Rigole
• Phone: (909)583-6505
• Email: [email protected]