What are the responsibilities and job description for the MEDICAL RECORDS TECH (HIT) position at Veterans Health Administration?
This position is in the Business Office Service Line - Health Information Management (HIM) section at the Washington DC Veterans Affairs Medical Center. The incumbent understands that the primary physical location of this position is the Mammography Clinic, but can be asked to relocate to support any clinical flow processes relating to access to care across multiple clinics, specialties (i.e., Comprehensive Breast Center), and/or care in the community resources.
Basic Requirements:
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)
(1) Experience. One year of experience equivalent to the next lower level. OR,
(2) 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).
(3) Demonstrated Knowledge, Skills, and Abilities. In addition to the experience above, the candidate must demonstrate all of the following KSAs: (a) Ability to communicate effectively with internal and external customers.
(b) 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). (c) Knowledge of health record documentation guidelines and industry standards. (d) Ability to manage priorities and coordinate work to complete duties within required timeframes. (e) 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
(1) Experience. One year of experience equivalent to the next lower grade level.
(2)Demonstrated Knowledge, Skills, and Abilities. In addition to the experience above, the candidate must demonstrate all of the following KSAs:
(a) Ability to navigate efficiently through the health record to locate needed information.
(b) Ability to analyze health record documentation to ensure compliance with guidelines and industry standards.
(c) Skill in investigating potential health record errors and making corrections, when appropriate.
(d) Skill in interpreting and applying health information guidelines and using judgment to complete assignments.
(e) Ability to follow up on incomplete health record documentation.
Medical Records Technician (HIT), GS-7 (Full Performance Level)
(1) Experience. One year of experience equivalent to the next lower grade level.
(2) 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 with HIM industry standards, policies, procedures, laws, regulations, and accreditation requirements. 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.
(3) Demonstrated Knowledge, Skills, and Abilities. In addition to the experience above, the candidate must demonstrate all of the following KSAs: (a) 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.
(b) Ability to take appropriate actions if health record content is not adequate, accurate, timely, and/or reliable.
(c) Ability to communicate both orally and in writing with individuals or groups, to facilitate compliance with established policies and regulations.
(d) Skill in using appropriate software and computer applications to analyze and record documentation trends.
(e) Ability to apply qualitative and/or quantitative methods for assessment and 7 improvement of health records.
(f) Ability to work independently and utilize problem-solving techniques in the accomplishment of work.
Reference: For more information on this qualification standard, please visit https://www.va.gov/ohrm/QualificationStandards/.
The full performance level of this vacancy is GS-07. The actual grade at which an applicant may be selected for this vacancy is in the range of GS-04 to GS-07.
Physical Requirements: Have the mental, emotional, and physical ability to satisfactorily perform the duties of the proposed assignment and to pass the requisite laboratory and other screening as required by Federal regulatory agencies.
Work Schedule: 8:00 am - 4:30 pm, Monday - Friday
Telework: Not Available
Virtual: This is not a virtual position.
Functional Statement #: 688-23127-F, 688-23128-F, 688-23129-F.
Relocation/Recruitment Incentives: Not Authorized
Permanent Change of Station (PCS): Not Authorized
Financial Disclosure Report: Not required
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
- Experience and Education.
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)
(1) Experience. One year of experience equivalent to the next lower level. OR,
(2) 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).
(3) Demonstrated Knowledge, Skills, and Abilities. In addition to the experience above, the candidate must demonstrate all of the following KSAs: (a) Ability to communicate effectively with internal and external customers.
(b) 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). (c) Knowledge of health record documentation guidelines and industry standards. (d) Ability to manage priorities and coordinate work to complete duties within required timeframes. (e) 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
(1) Experience. One year of experience equivalent to the next lower grade level.
(2)Demonstrated Knowledge, Skills, and Abilities. In addition to the experience above, the candidate must demonstrate all of the following KSAs:
(a) Ability to navigate efficiently through the health record to locate needed information.
(b) Ability to analyze health record documentation to ensure compliance with guidelines and industry standards.
(c) Skill in investigating potential health record errors and making corrections, when appropriate.
(d) Skill in interpreting and applying health information guidelines and using judgment to complete assignments.
(e) Ability to follow up on incomplete health record documentation.
Medical Records Technician (HIT), GS-7 (Full Performance Level)
(1) Experience. One year of experience equivalent to the next lower grade level.
(2) 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 with HIM industry standards, policies, procedures, laws, regulations, and accreditation requirements. 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.
(3) Demonstrated Knowledge, Skills, and Abilities. In addition to the experience above, the candidate must demonstrate all of the following KSAs: (a) 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.
(b) Ability to take appropriate actions if health record content is not adequate, accurate, timely, and/or reliable.
(c) Ability to communicate both orally and in writing with individuals or groups, to facilitate compliance with established policies and regulations.
(d) Skill in using appropriate software and computer applications to analyze and record documentation trends.
(e) Ability to apply qualitative and/or quantitative methods for assessment and 7 improvement of health records.
(f) Ability to work independently and utilize problem-solving techniques in the accomplishment of work.
Reference: For more information on this qualification standard, please visit https://www.va.gov/ohrm/QualificationStandards/.
The full performance level of this vacancy is GS-07. The actual grade at which an applicant may be selected for this vacancy is in the range of GS-04 to GS-07.
Physical Requirements: Have the mental, emotional, and physical ability to satisfactorily perform the duties of the proposed assignment and to pass the requisite laboratory and other screening as required by Federal regulatory agencies.
Responsibilities:
Range of major duties:- MRTs HIT perform incomplete health record analysis.
- Review, analyze, abstract, maintain, extract, and compile information from the health record.
- Check for accuracy, completeness, and timeliness of the health record and monitor and report for regulatory compliance.
- Serve as the technical experts in health record content and documentation requirements.
- Communicate regularly with staff at various levels of the organization regarding delinquent health records, and notify individual clinical providers regarding incomplete medical records.
- 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.
- 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.
Work Schedule: 8:00 am - 4:30 pm, Monday - Friday
Telework: Not Available
Virtual: This is not a virtual position.
Functional Statement #: 688-23127-F, 688-23128-F, 688-23129-F.
Relocation/Recruitment Incentives: Not Authorized
Permanent Change of Station (PCS): Not Authorized
Financial Disclosure Report: Not required
Salary : $41,247
