This position is located in the Health Information Management (HIM) Service in the Business Operations Program of the Veterans Healthcare System of the Ozarks, Fayetteville, Arkansas. MRTs HIT perform incomplete health record analysis by reviewing, analyzing, abstracting, maintaining, extracting, and compiling 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

The duties of the Medical Records Technician (Health Information Technician) include, but are not limited to: Serves as technical expert in health record content and documentation requirements. Perform quantitative and qualitative reviews of health record documentation. Ensures that all patient care data entered in VistA and/or Computerized Patient Record System (CPRS) is accurate, timely, and completed. 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. Reviews records to include notes, consults, and orders to determine correct importing of community care records. Assists clinicians with completion of delinquent/incomplete health records. Consults with the appropriate clinician(s) for clarification when conflicting or ambiguous information appears in the health record documentation. Identifies health record deficiencies, tracks deficiencies and ensures that the appropriate individual completes their deficiencies. Assists physicians with the completion of delinquent/incomplete health records and servers as the expert resource for clinical staff regarding requirements for complete documentation. Assesses the paper health record and electronic Computerized Patient Record System (CPRS) for completeness and notes deficiencies in the appropriate data base(s). Tracks electronic signatures and documents deficiencies and communicates these deficiencies to clinical staff for correction. Prepares complex weekly and monthly reports noting the status of all incomplete/delinquent records and compliance reports and submits the reports to the appropriate administrative and clinical staff. 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. Performs analytical tasks associated with the resolution of "filing" errors on reports uploaded by a transcription vendor. Identifies reviews, verifies, and corrects all statistical data concerning medical transcription to maintain accuracy of medical and statistical reports. Works with interdisciplinary staff to solve problems regarding proper health record documentation and completion. Contacts physicians and other ancillary service personnel regarding dictation and/or signatures. Assists medical staff by providing information as to required documentation. Communicates very closely with the medical staff to answer questions and resolve problems to ensure quality documentation in the health records. Participates in routine and focused reviews for the purpose of identifying problems and potential problems in record documentation as part of the health record review process. Identifies and abstracts information from health records for special studies and audits both internal and external. Work Schedule: Monday through Friday, 8:00 am - 4:30 pm (subject to change based on the needs of the agency) Telework: Available Virtual: This is not a virtual position. Functional Statement #: 00001F, 00002F, 00003F, 00004F 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. (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. 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): (1) Experience or Education. None beyond basic requirements. (2) Assignment. Employees at this level serve as entry level MRTs HIT, and receive close supervision from the supervisory MRT HIT or designee. MRTs HIT 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. Medical Records Technician (HIT), GS-5 (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). 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 time frames. 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 Experience. One year of experience equivalent to the next lower grade level. This is a developmental level for MRT(HITs). The MRT (HIT) at this level receives guidance from the supervisory MRT (HIT) or designee, for more complex health records. The MRT HIT analyzes, abstracts, maintains, extracts and compiles information from the health record, working under the review of the supervisor. 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 coordinate and/or perform health record review activities to satisfy external accreditation requirements and medical center performance measures. The MRT HIT notifies clinical providers regarding incomplete health records. They assist clinical providers regarding completeness of their health record documentation, and the correction of health records. They conduct reviews of incomplete records for individuals clearing the facility. They create and monitor reports to ensure that deficiencies are resolved and completed appropriately. They monitor, verify, correct, and/or upload all transcription/medical speech recognition to maintain completeness and accuracy of health records. MRTs HIT serve as the technical experts in health record content and documentation requirements. Grade Determination for Medical Records Technician (HIT), GS-7 (Full Performance Level) Continued in Education Section. Preferred Experience: One year experience reviewing the medical record for completeness and compliance which can include scanning, uploading or importing, indexing and linking documents to the correct consults to ensure the electronic medical record meets Health Information Management (HIM) industry standards. References: VA Handbook 5005/124, Part II, Appendix G-59 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: This position is primarily sedentary. Work includes walking, sitting/standing at desk, bending, keyboarding and use of mouse, and carrying light items.

Education

GS-7 Grade Determination Continued.

Medical Records Technician (HIT), GS-7 (Full Performance Level)
Experience. One year of experience equivalent to the next lower grade level. 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.

In addition to the experience above, the candidate must demonstrate all of the following KSAs:

1. 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.
2. Ability to take appropriate actions if health record content is not adequate, accurate, timely, and/or reliable.
3. Ability to communicate both orally and in writing with individuals or groups, to facilitate compliance with established policies and regulations.
4. Skill in using appropriate software and computer applications to analyze and record documentation trends.
5. Ability to apply qualitative and/or quantitative methods for assessment and improvement of health records.
6. Ability to work independently and utilize problem-solving techniques in the accomplishment of work.

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 Fayetteville AR VA Medical Center 1100 North College Avenue Fayetteville, AR 72703 US
• Name: SUSAN WILLIAMS
• Phone: 228-523-4934
• Email: [email protected]