The Ft. Harrison VA Health Care System located in Montana is currently recruiting for a GS 4, 5, 6 or 7 Medical Records Technician-Health Information Technician to work in the Health Information Management Section.

Duties

Medical Records Technician-Health Information Technician duties in the Health Information Management Section duties include, but aren't limited to the following: Serves as technical expert for health record content & documentation requirements & ensures all patient care data entered in VistA & Computerized Patient Record System (CPRS) is accurate, timely & complete Adheres to established documentation requirements as outlined by The Joint Commission regulations, Veterans Health Administration (VHA) guidelines & medical-legal requirements Reviews records for adherence w/ CMS guidelines related to student, resident supervision & attending physician presence & documentation Compiles reports to ensure provider specific & service compliance Maintains control system to ensuring completion of all inpatient & outpatient records according to VA, The Joint Commission, CMS & other regulatory agencies standards Reviews health records to make certain all records contain sufficient information to meet medical/legal requirements patient care continuity & support education/research needs Performs quantitative/qualitative analysis on computer & paper-based health records Receives clarification from clinicians when conflicting or ambiguous information appears in health record documentation Assesses paper health records & electronic Computerized Patient Record System (CPRS) for completeness & notes deficiencies Identifies health record deficiencies, tracks them & ensures the appropriate individual completes/fixes their deficiencies Assists physicians completing delinquent/incomplete health records & serves as an expert resource for clinical staff regarding requirements for complete documentation Prepares complex weekly & monthly reports, notes status of all incomplete/delinquent records & compliance reports & submits reports to appropriate administrative/clinical staff Responsible for expediting health record completion due to patient transfers to another medical center, for legal requests, regulatory agencies review & for reimbursement purposes Performs analytical tasks associated "filing" error resolutions for reports uploaded by transcription vendors; including correctly identifying the patient the report belongs to & filing/assigning it correctly, generating various statistical reports to track errors, making appropriate recommendations for changes or solutions & implementing appropriate recommendations for corrective action when authorized to eliminate subsequent errors Identifies reviews, verifies & corrects all statistical data concerning medical transcription to maintain accuracy of medical & statistical reports Compares & resolves discrepancies between daily Gains and Losses Sheet, Digital System Workload Report & contract transcription logs as they relate to timeliness & accuracy of dictated reports completed by medical transcription contractors Reviews health records for adherence w/ guidelines related to resident supervision & attending physician presence Works w/ interdisciplinary staff to solve problems regarding proper health record documentation & completion Develops & compiles written reports trending provider specific, service & hospital compliance reports regarding admissions subsequent & discharge notes Obtains statistical information, applies statistical formulas & completes statistical reports for medical center management Prepares weekly & monthly reports noting all incomplete/delinquent health records status' & submits reports to appropriate administrative & clinical staff Participates in routine & focused reviews to identify problems/potential problems in record documentation as part of the health record review process Identifies & redacts information from internal & external health records for special studies & audits Demonstrates I-Care values when interacting w/ all internal/external customers Maintains current knowledge of & practices in accordance w/ The Joint Commission requirements Protects printed & electronic files containing sensitive data according to Federal privacy Act & confidentiality statutes Follows regulations & instructions regarding release of sensitive/protected patient/ employee information May serve on Service Line/VISN 19/medical center committees, workgroups, &/or task forces, etc. Performs other duties as assigned Work Schedule: Monday-Friday 8:00am-4:30pm Virtual: This is a virtual position Functional Statement #: PD04-58477A, 05-58478A, 06-58479A, 06-58480A Relocation/Recruitment Incentives: 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. Applicants must be proficient in spoken & written English 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: (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. Grade Determinations: All MRT HIT employees assigned to this occupation must have an approved parenthetical title as described below: GS-4 Experience or Education. None beyond basic requirements GS-5 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. Candidates must demonstrate all the following KSAs in addition to the experience above: 1) Ability to communicate effectively with internal and external customers 2) 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 3) Knowledge of health record documentation guidelines and industry standards 4) Ability to manage priorities and coordinate work to complete duties within required timeframes 5) Ability to apply knowledge of medical terminology and human anatomy to fully understand the content of a health record GS-6 Experience. One year of experience equivalent to the next lower grade level Demonstrated Knowledge, Skills, and Abilities. Candidates must demonstrate all the following KSAs in addition to the experience above: 1) Ability to navigate efficiently through the health record to locate needed information 2) Ability to analyze health record documentation to ensure compliance with guidelines and industry standards 3) Skill in investigating potential health record errors and making corrections, when appropriate 4) Skill in interpreting and applying health information guidelines and using judgment to complete assignments 5) Ability to follow up on incomplete health record documentation GS-7 Experience. One year of experience equivalent to the next lower grade level Demonstrated Knowledge, Skills, and Abilities. Candidates must demonstrate all the following KSAs in addition to the experience above: 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 References: VA Handbook 5005/124 PART II APPENDIX G59 The full performance level of this vacancy is a GS-7. The actual grade at which an applicant may be selected for this vacancy is in the range of a GS-4 to a GS-7. Physical Requirements: Long periods of sitting, standing, bending and walking. May require lifting/carrying light items up to 30 pounds on an occasional basis. Occasional heavy lifting of equipment/materials, (e.g. paper boxes over 30 pounds) Must be able to work at a desk in front of a monitor/screen several hours per day, using a mouse and keyboard.

Education

IMPORTANT: A transcript must be submitted with your application if you are basing all or part of your qualifications on education. Transcripts can be unofficial transcripts, but must include your name, the school's entire name, the name of the course, date course taken, grade received for the course, amount of credits earned for the course, date degree conferred, (if applicable), (name of degree received, (if applicable).

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 Montana VA Health Care System 3687 Veterans Drive Fort Harrison, MT 59636 US
• Name: VISN 19 HR Contact Center
• Phone: 719-227-4600
• Email: [email protected]