Medical Records Technician (Health Information Technician)

Veterans Health Administration • Syracuse, NY

3d • Onsite

About The Position

This position is in the Health Information Management (HIM) section at the Syracuse VA Medical Center. The Medical Records Technician (Health Information Technician) performs quantitative and qualitative reviews of paper and electronic health records to assess accuracy, completeness, timeliness, and regulatory compliance. The technician reviews, analyzes, abstracts, maintains, extracts, and compiles information from health records, including data entered in VistA and/or the Computerized Patient Record System (CPRS). The role supports medical-legal requirements, continuity of patient care, education, research, and reimbursement needs.

The technician identifies, tracks, and communicates documentation deficiencies; assists clinicians with completing delinquent or incomplete records; and consults clinicians when documentation is conflicting or ambiguous. The position independently addresses health-record deficiency issues and erroneous documents in CPRS, seeking guidance when no precedent or procedure exists. It also involves reviewing transcription-related filing errors and statistical data, preparing compliance and status reports, and participating in routine and focused reviews and audits.

The position is not virtual. The work schedule is Monday through Friday, either 7:00 a.m.–3:30 p.m. or 7:30 a.m.–4:00 p.m. The full performance level is GS-07; selection may be at GS-04 through GS-07.

Requirements

• U.S. citizenship, subject to the stated exception for non-citizens when qualified citizens cannot be recruited under VA policy.
• Proficiency in written and spoken English.
• Meet the basic qualification requirements through one of the stated pathways: one year of qualifying experience; an associate's degree in health information technology/management or a related degree with at least 12 semester hours in the field; or an equivalent combination of qualifying experience and education/training.
• For GS-5 through GS-7 grade determinations, meet the stated grade-specific experience or education requirements and demonstrate the corresponding knowledge, skills, and abilities.
• 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 within required timeframes.
• Knowledge of medical terminology and human anatomy sufficient to understand health-record content.
• Ability to navigate health records efficiently and locate needed information.
• Ability to analyze documentation for compliance, investigate potential record errors, make corrections when appropriate, and follow up on incomplete documentation.
• Ability to interpret and apply health information guidelines and use judgment to complete assignments.
• Ability to determine whether records are sufficient for regulatory requirements, acceptable as legal documents, adequate for continuity of care, and supportive of education and research.
• 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 with policies and regulations.
• 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, work independently, and use problem-solving techniques.
• Meet applicable pre-employment identification, onboarding, background/security investigation, and seasonal influenza vaccination requirements.
• Serve a one- or two-year trial period, as applicable, subject to the stated employment evaluation and certification conditions.

Responsibilities

• Perform quantitative and qualitative reviews of health-record documentation, including paper records and electronic records in CPRS.
• Ensure patient-care data entered in VistA and/or CPRS is accurate, timely, and complete.
• Apply documentation requirements under The Joint Commission regulations, VHA guidelines, CMS guidelines, and medical-legal requirements.
• Review records for compliance with guidelines concerning student and resident supervision and attending physician presence and documentation.
• Maintain a control system for completion of inpatient and outpatient records in accordance with VA and other regulatory standards.
• Assess records for sufficient information to meet medical-legal requirements, support continuity of care, and meet education and research needs.
• Identify, track, and communicate deficiencies and follow up to ensure the responsible individuals complete them.
• Assist clinicians and physicians with completing delinquent or incomplete health records, and serve as a resource to clinical staff on documentation requirements.
• Expedite health-record completion when records are needed for transfers to other medical centers, legal requests, regulatory reviews, or reimbursement.
• Track electronic signatures and communicate deficiencies to clinical staff through normal notification channels.
• Independently resolve health-record deficiency issues and erroneous documents in CPRS, seeking guidance when no precedent or procedure exists.
• Prepare weekly and monthly reports on incomplete and delinquent records and compliance, and submit them to administrative and clinical staff.
• Analyze and resolve filing errors in reports uploaded by a transcription vendor, including identifying the correct patient and filing or assigning reports appropriately.
• Generate statistical reports on transcription filing errors, recommend solutions, and implement authorized corrective actions.
• 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 regarding report timeliness and accuracy.
• Work with interdisciplinary staff to resolve health-record documentation and completion issues.
• Develop and compile reports on provider-specific, service, and hospital compliance regarding admission, subsequent, and discharge notes.
• Obtain statistical information, apply statistical formulas, and prepare reports for medical center management.
• Participate in routine and focused reviews to identify documentation problems and potential problems.
• Identify and abstract health-record information for internal and external special studies and audits.
• Perform other duties as assigned.

Benefits

• A federal employee benefits package is available to eligible employees and their families; specific benefits depend on position type and eligibility.
• Selected applicants may qualify to receive credit for prior work or military service toward annual leave accrual, subject to request and approval before appointment.

What This Job Offers

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