Medical Records Technician (HIT)

Veterans Health Administration•Billings, MT

3d•Onsite

About The Position

This position is in the Health Information Management section at the Montana VA Healthcare System. The Medical Records Technician (HIT) performs incomplete health record analysis by reviewing, analyzing, abstracting, maintaining, extracting, and compiling information from health records. The technician checks health records for accuracy, completeness, and timeliness and monitors and reports regulatory compliance. The role performs quantitative and qualitative reviews of computer-based and paper health records, ensuring patient-care data entered in VistA and/or CPRS is accurate, timely, and complete. The technician applies documentation requirements established by The Joint Commission, Veterans Health Administration, CMS, and other medical-legal and regulatory standards. The position supports clinicians and interdisciplinary staff in resolving documentation issues and completing delinquent or incomplete records, and expedites records needed for transfers, legal requests, regulatory reviews, and reimbursement. The technician identifies, tracks, and follows up on record deficiencies; consults clinicians when documentation is conflicting or ambiguous; and prepares statistical, compliance, and delinquency reports for administrative and clinical staff. The role also reviews and reconciles transcription-related statistical data and abstracts information for internal and external studies and audits. The full performance level is GS-7; selections may be made at GS-4 through GS-7.

Requirements

U.S. citizenship, except where appointment of a non-citizen is permitted under VA policy.
Proficiency in written and spoken English.
Meet the basic experience and education requirements through one of the listed pathways: one year of creditable experience involving medical terminology, anatomy, physiology, and general health-record knowledge (including six months with KSAs needed for MRT HIT work); an associate's degree in health information technology/management or a related degree with at least 12 semester hours in that field; or an acceptable combination of experience and education/training.
Meet the applicable grade-level qualifications: GS-4 requires no experience or education beyond the basic requirements; GS-5, GS-6, and GS-7 require one year of experience equivalent to the next lower level or qualifying education where specified, plus the grade-specific KSAs.
For GS-5, demonstrate effective communication, ability to use health information technology and office software, knowledge of health record documentation guidelines and standards, ability to manage priorities and meet timeframes, and application of medical terminology and anatomy knowledge.
For GS-6, demonstrate efficient health-record navigation, documentation analysis for compliance, investigation and appropriate correction of potential errors, interpretation and application of health information guidelines, sound judgment, and follow-up on incomplete documentation.
For GS-7, demonstrate judgment of record sufficiency for regulatory and legal requirements, continuity of care, education, and research; appropriate action when documentation is inadequate or unreliable; oral and written communication; use of software to analyze and record trends; application of qualitative and quantitative assessment methods; and independent problem-solving.
Register with Selective Service if a male born after December 31, 1959.
Complete a background/security investigation and required online onboarding and pre-employment identification requirements.
Participate in the seasonal influenza vaccination program as a VA Health Care Personnel employee.
Serve a one- or two-year trial period, subject to written certification for continued employment.
If qualifying through foreign education, provide a Certificate of Foreign Equivalency with the transcript.

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, The Joint Commission, CMS, and other regulatory, documentation, and medical-legal requirements.
Maintain a control system to ensure inpatient and outpatient records are completed in accordance with applicable standards.
Identify, track, and follow up on health record deficiencies, ensuring the appropriate individuals complete them.
Assist clinicians and physicians with completing delinquent or incomplete health records and advise clinical staff on documentation requirements.
Consult appropriate clinicians to clarify conflicting or ambiguous health record documentation.
Expedite completion of records for patient transfers, legal requests, regulatory reviews, and reimbursement purposes.
Review records for requirements concerning student and resident supervision and attending physician presence and documentation.
Compile provider-specific, service, and hospital compliance reports, including reports on admission, subsequent, and discharge notes.
Prepare weekly and monthly reports on incomplete and delinquent health records for administrative and clinical staff.
Identify, review, verify, and correct statistical data concerning medical transcription; compare and resolve discrepancies among daily Gains and Losses Sheets, Digital System Workload Reports, and contract transcription logs.
Obtain statistical information, apply statistical formulas, and complete reports for medical center management.
Participate in routine and focused health record reviews to identify documentation problems and potential problems.
Identify and abstract health record information for internal and external studies and audits.
Work with interdisciplinary staff to resolve health record documentation and completion problems.