Medical Records Technician (HIT)

Veterans Health Administration • Manchester, NH

9d • Onsite

About The Position

This Medical Records Technician (HIT) position is in the Business Office at the Manchester VA Medical Center in Manchester, New Hampshire. The position is part of an open and continuous announcement establishing a standing register of eligible applicants through December 29, 2026. The initial referral cutoff is on or about October 11, 2026, with additional reviews every other week or as vacancies arise until positions are filled. The full-performance level is GS-07, and selections may be made at GS-04 through GS-07.

The technician serves as a technical expert in health record content and documentation requirements. The role involves quantitative and qualitative reviews of paper and electronic health records, including information in VistA and CPRS, to ensure accuracy, completeness, timeliness, consistency, and compliance with applicable standards. The technician reviews records against VA, VHA, The Joint Commission, CMS, and other regulatory and medical-legal requirements; identifies and tracks deficiencies; communicates them to clinical staff; and supports their correction. The incumbent also assists clinicians with incomplete or delinquent documentation and works independently to resolve record issues when procedures or precedents exist.

The position maintains systems for completing inpatient and outpatient records, prepares weekly and monthly reports on delinquent records and compliance, and expedites record completion for transfers, legal requests, regulatory reviews, and reimbursement purposes. Work is scheduled Monday through Friday, 8:00 a.m. to 4:30 p.m. Ad hoc telework may be available; the position is not virtual. A pre-employment physical evaluation is required. Relocation and recruitment incentives and permanent change of station are not authorized.

Requirements

• U.S. citizenship.
• Proficiency in written and spoken English.
• One year of creditable experience demonstrating knowledge of medical terminology, anatomy, physiology, and a general understanding of health records, with at least six months providing KSAs needed for MRT HIT work; OR an associate's degree in health information technology/health information management or a related degree with at least 12 semester hours in the field; OR an eligible combination of experience and education/training described in the announcement.
• For GS-5, one year of experience equivalent to the next lower level or a qualifying bachelor's degree with a major in health information management or a related degree with at least 24 semester hours in health information technology/management, plus the stated KSAs.
• For GS-6, one year of experience equivalent to the next lower grade level, plus the stated KSAs.
• For GS-7, one year of experience equivalent to the next lower grade level, plus the stated KSAs.
• Ability to communicate effectively with internal and external customers.
• Ability to use health information technology and office software used in health information management, such as 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 meet required timeframes.
• Ability to apply medical terminology and human anatomy knowledge to understand health record content.
• Ability to navigate health records efficiently and locate needed information.
• Ability to analyze health record documentation for compliance and investigate potential errors, making corrections when appropriate.
• Skill in interpreting and applying health information guidelines and using judgment to complete assignments.
• Ability to follow up on incomplete documentation.
• Ability to judge whether records satisfy regulatory requirements, are acceptable legal documents, support continuity of care, and meet education and research needs.
• Ability to take appropriate action when record content is inadequate, inaccurate, untimely, or unreliable.
• Ability to communicate orally and in writing with individuals or groups to facilitate compliance.
• Skill in using software and computer applications to analyze and record documentation trends.
• Ability to apply qualitative and/or quantitative methods to assess and improve health records.
• Ability to work independently and use problem-solving techniques.
• Complete the application, questionnaire, online assessment, and all other required application steps.
• Meet applicable Selective Service registration requirements for males born after December 31, 1959.
• Subject to background/security investigation and online onboarding requirements.
• Pass a pre-employment physical evaluation and participate in the seasonal influenza vaccination program.
• Serve a one- or two-year trial period and receive written certification for continued employment after that period.

Responsibilities

• Perform quantitative and qualitative reviews of paper and electronic health records.
• Ensure patient care data entered in VistA and/or CPRS is accurate, timely, and complete.
• Review health records for compliance with VA, VHA, The Joint Commission, CMS, medical-legal, and other applicable documentation requirements.
• Maintain a control system to ensure timely completion of inpatient and outpatient health records.
• Assess records for sufficient information to meet legal requirements, support continuity of care, and serve education and research needs.
• Identify, track, and communicate health record deficiencies, including missing electronic signatures, and ensure appropriate staff correct them.
• Assist clinicians with completing delinquent or incomplete health records and provide guidance on documentation requirements.
• Consult clinicians to clarify conflicting or ambiguous health record information.
• Resolve health record deficiency issues and erroneous documents within CPRS, seeking supervisory or Clinical Application Coordinator guidance when no precedent or procedure exists.
• Expedite completion of health records for patient transfers, legal requests, regulatory reviews, and reimbursement purposes.
• Prepare complex weekly and monthly reports on incomplete or delinquent records and compliance, and submit them to appropriate administrative and clinical staff.
• Review incomplete records for individuals clearing the facility and create and monitor reports to ensure deficiencies are appropriately resolved.
• Review records for compliance with CMS guidelines regarding student and resident supervision and attending physician presence and documentation.
• Compile reports on provider-specific and service compliance.

Benefits

• Federal employee benefits package; specific benefits depend on position type and eligibility.
• Potential credit toward annual leave accrual for prior work or military service, subject to request and approval.

What This Job Offers

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