Medical Records Technician - Health Information Technician

Veterans Health Administration • Sheridan, WY

18h • Onsite

About The Position

This position is located in the Health Information Management (HIM) section at the Sheridan Wyoming VA Medical Center. Medical Records Technicians (MRTs) / Health Information Technicians (HITs) perform incomplete health record analysis. They review, analyze, abstract, maintain, extract, and compile information from the health record. MRTs HITs check for accuracy, completeness, and timeliness of the health record and monitor and report for regulatory compliance. They routinely scan paper and electronic documents to the Electronic Health Record (EHR) ensuring proper and timely placement in the medical record.

Requirements

• Must be a U.S. Citizen.
• Selective Service Registration is required for males born after 12/31/1959.
• Must be proficient in written and spoken English.
• Subject to background/security investigation.
• Selected applicants will be required to complete an online onboarding process.
• Acceptable form(s) of identification will be required to complete pre-employment requirements.
• Effective May 7, 2025, driver's licenses or state-issued identification cards that are not REAL ID compliant cannot be utilized as an acceptable form of identification for employment.
• Participation in the seasonal influenza vaccination program is a requirement for all Department of Veterans Affairs Health Care Personnel (HCP).
• Complete all application requirements detailed in the "Required Documents" section of this announcement.
• As a condition of employment for accepting this position, you will be required to serve a 1 or 2-year trial period.
• 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.
• 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.
• 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.
• 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.
• 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.

Nice To Haves

• Telework: Available on an ad-hoc basis.

Responsibilities

• Serves as technical expert in health record content and documentation requirements.
• Responsible for performing quantitative and qualitative reviews of health record documentation for ongoing regulatory reviews and deficiency analysis.
• Responsible for ensuring that all patient care data entered in the electronic health record (EHR) is accurate, timely, and complete.
• Adheres to established documentation requirements as outlined by The Joint Commission (TJC) regulations, Veterans Health Administration (VHA) guidelines, as well as medico-legal requirements.
• Reviews health records for adherence with the Centers for Medicare and Medicaid Services (CMS) guidelines related to student, resident supervision and attending physician presence and documentation.
• Compiles reports to ensure provider specific and service compliance.
• Maintains a control system to ensure completion of all inpatient and outpatient health records in accordance with VHA, TJC, CMS and other regulatory agencies' standards.
• Reviews health records to ensure that all health records contain sufficient information to meet medico-legal requirements, to ensure continuity of patient care, and to support education and research needs.
• Notifies clinicians of missing, incomplete, or inaccurate information in their signature blocks (e.g., missing or inaccurate credentials).
• Assist clinicians with completion of delinquent/incomplete health records.
• Assesses the health record for completeness, identifies health record deficiencies, tracks deficiencies, and ensures that the appropriate individuals complete their deficiencies.
• Notates documentation deficiencies in the appropriate deficiency monitoring application.
• Tracks unsigned/un-cosigned notes (e.g., progress notes, operative reports, discharge summaries, etc.) and encounters without associated progress notes and communicates these deficiencies to clinical staff for completion.
• Responsible for expediting 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.
• Performs analytical tasks associated with the resolution of "filing" errors on reports uploaded by a transcription vendor. This includes correctly identifying the patient the report belongs to and filing/assigning it correctly.
• If site utilizes Dragon and assigns medical speech recognition (MSR) duties to the HIM Department, coordinates and monitors the use of medical speech recognition and troubleshoots with clinicians, as needed, to maintain completeness and accuracy of health records.
• Provides Dragon Local Administrator duties that typically include: creating new user accounts in the Nuance Management Center, act as a local POC for Dragon questions, referrals and guidance, troubleshoot technical problems with local IT as needed, assist clinical end users with log on and provide user guides, create and maintain a facility Dragon User Outlook mail group to facilitate MSR communications, submit tickets to Nuance Government Support, as needed, listen in and participate on the VHA MSR Administration calls, provide training tools and resources, facilitate purchase and distribution of headsets/microphones as needed, and provide Dragon usage reports to leadership.
• Works with interdisciplinary staff to solve problems regarding proper health record documentation and completion.
• Consults with the appropriate clinician(s) for clarification when conflicting or ambiguous information appears in the health record documentation.
• Prepares complex reports on a routine basis, noting the status of all incomplete/delinquent health records, and submits the reports to the appropriate administrative and clinical staff.
• Develops and compiles written reports trending provider specific, service, and hospital compliance reports regarding admission, subsequent and discharge progress notes.
• Obtains statistical information, applies statistical formulas, and completes statistical reports for medical center management.

Benefits

• A career with the U.S. government provides employees with a comprehensive benefits package.
• As a federal employee, you and your family will have access to a range of benefits that are designed to make your federal career very rewarding.
• Eligibility for benefits depends on the type of position you hold and whether your position is full-time, part-time or intermittent.

What This Job Offers

• Job Type: Full-time
• Career Level: Entry Level
• Education Level: Associate degree