This position is located in the Health Information Management (HIM) section at the Atlanta VA Medical Center. MRTs HIT perform 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

Duties include, however, not limited to: Incumbent serves as technical expert in health record content and documentation requirements. Incumbent is responsible for performing quantitative and qualitative reviews of health record documentation. Adheres to established documentation requirements as outlined by The Joint Commission regulations, Veterans Health Administration (VHA) guidelines, as well as medical-legal requirements. Reviews records for adherence with CMS guidelines related to student, resident supervision and attending physician presence and documentation. Compiles reports to insure provider specific and service compliance. Maintains 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. 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. Assists clinicians with completion of delinquent/incomplete health records. Performs the quantitative and qualitative analysis on both computer and paper based 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 serves as the expert resource for clinical staff regarding requirements for complete documentation. Expedites the completion of the health record when the patient is transferred for care at another medical center, for legal requests, regulatory agencies review, and reimbursement purposes. Assesses the paper health record and electronic Computerized Patient Record System (CPRS) for completeness and notes deficiencies in the (insert name of record deficiency monitoring system such as IRT, Nuance, etc). Tracks electronic signatures and documents deficiencies and communicates these deficiencies to clinical staff for correction. Works independently resolving health record deficiency issues/erroneous documents and corrective action required within CPRS and only seeks guidance of immediate supervisor and/or Clinical Application Coordinator when issues surface when no precedent or procedure has been developed. Work Schedule: Monday - Friday, 6:00AM - 2:30PM Telework: Available Virtual: This is not a virtual position. Functional Statement #: 55344F Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized

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. Experience and/or Education. 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, 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. 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, GS-07 Experience. One year of experience equivalent to the next lower grade level. 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. 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. Reference: VA Handbook 5005/124 PART II APPENDIX G59. For more information on this qualification standard, please visit https://www.va.gov/ohrm/QualificationStandards/. The full performance level of this vacancy is GS-7. Physical Requirements: The work is sedentary, but may require walking, bending, standing, and /or carrying of light items such as files and manuals. The work does not require any special physical effort or ability.

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 Atlanta VA Medical Center 1670 Clairmont Road Decatur, GA 30033 US
• Name: Donna Mackey-Pollard
• Phone: 334-590-9523
• Email: [email protected]