Medical Records Technician (Health Information Technician)

Veterans Health Administration•New Orleans, LA

4d•Onsite

About The Position

This position is in the Health Information Management (HIM) section at the Southeast Louisiana Veterans Healthcare System. The Medical Records Technician (Health Information Technician) performs incomplete health record analysis by reviewing, analyzing, abstracting, maintaining, extracting, and compiling information from health records. The technician checks records for accuracy, completeness, and timeliness and monitors and reports on regulatory compliance. The role supports ongoing regulatory reviews, deficiency analysis, quality improvement, accreditation requirements, and facility performance measures. It involves working closely with physicians and other clinical personnel to resolve documentation issues and support complete, accurate health records. The position is not virtual. Telework is available, and the work schedule is Monday through Friday, 7:30 a.m. to 4:00 p.m., subject to change based on facility needs. The position may be filled at GS-04 through GS-07, with GS-07 as the full performance level. The work is performed in an office clinic setting. Physical demands may include standing, lifting, carrying, sitting, stooping, bending, pulling, and pushing; personal protective equipment and annual tuberculosis screening or testing may be required.

Requirements

U.S. citizenship, subject to the stated exception for appointments when qualified citizens cannot be recruited.
Proficiency in spoken and written English.
Meet the basic experience or education requirements: one year of creditable experience involving medical terminology, anatomy, physiology, and general understanding of health records, including six months providing MRT HIT KSAs; or a qualifying associate degree; or an eligible combination of experience and education or training.
For GS-5, meet the grade-level experience or education requirement and demonstrate effective communication, ability to use health information technology and office software, knowledge of documentation guidelines and industry standards, ability to manage priorities and meet timeframes, and ability to apply medical terminology and anatomy knowledge.
For GS-6, have one year of experience equivalent to the next lower grade and demonstrate efficient health-record navigation, documentation compliance analysis, investigation of potential record errors, application of health information guidelines and judgment, and follow-up on incomplete documentation.
For GS-7, have one year of experience equivalent to the next lower grade and demonstrate ability to assess records for regulatory, legal, patient-care, education, and research sufficiency; take appropriate action on inadequate or inaccurate content; communicate policies and regulations; use software to analyze and record documentation trends; apply qualitative or quantitative assessment methods; and work independently using problem-solving techniques.
Pass a pre-employment physical evaluation and a background/security investigation.
Complete the online onboarding process and provide acceptable identification for pre-employment requirements.
Register with Selective Service if applicable to males born after December 31, 1959.
Participate in the seasonal influenza vaccination program.
Serve a one- or two-year trial period, as required.

Nice To Haves

Tech-savvy and able to quickly learn new software, electronic health records, and deficiency-tracking or health information systems.
Intermediate-to-expert Microsoft Office skills, including Word, Excel, PowerPoint, and Outlook, with experience generating statistical or compliance reports and analyzing data.
Experience conducting quantitative and qualitative health record reviews for regulatory compliance, including TJC, CMS, or VHA requirements.
Familiarity with medical speech recognition systems such as Dragon/Nuance and transcription workflows, including troubleshooting and local administration.
Experience tracking, trending, and reporting health record deficiencies and communicating them to clinical staff.
Experience delivering presentations and developing documentation-requirements training for clinical and non-clinical staff.
Ability to manage concurrent projects and competing deadlines while maintaining accuracy.
LEAN or Lean Six Sigma training or certification.

Responsibilities

Abstract clinical information for ongoing regulatory reviews and deficiency analysis.
Contact physicians and ancillary service personnel regarding dictation and signatures, and provide clinical staff with information about documentation requirements.
Work closely with clinical staff to answer questions and resolve problems affecting health record documentation quality.
Capture and report health record documentation deficiencies and record them in the appropriate deficiency-monitoring application.
Monitor delinquent dictation lists and follow up on documents needed to complete health records, including operation reports and discharge summaries.
Notify physicians and other personnel about the status of dictation and monitor house staff rotation schedules to ensure records are completed before residents leave the Medical Center.
Participate in approved quality-improvement focused reviews and coordinate review activities with the Quality Improvement Program for external accreditation and facility performance measures.
Use knowledge of medical terminology, anatomy, physiology, and coding to research and collect information for medical studies and research projects.
Collect, interpret, and trend data from validation activities and audits supporting patient-care continuity, resource allocation, performance measurement, quality management, research, comparative analysis, and benchmarking.
Track unsigned or un-cosigned notes and encounters without associated progress notes, and communicate deficiencies to clinical staff for completion.
Assist physicians and clinicians with delinquent or incomplete health records and serve as a resource on complete-documentation requirements.
Prepare routine complex reports on incomplete and delinquent health records for administrative and clinical staff.
Review records for sufficient information to meet medico-legal requirements, support continuity of care, and meet education and research needs.
Notify clinicians of missing, incomplete, or inaccurate information in signature blocks, including credentials.
Resolve incomplete-record deficiencies and erroneous documentation issues independently, referring issues to the supervisor when no precedent or procedure exists.
Conduct routine and focused reviews to identify actual or potential health record documentation problems.
Identify and abstract information from health records for internal and external special studies and audits.