Medical Records Technician (Health Information Technician)

Veterans Health Administration • Saint Cloud, MN

4d • Onsite

About The Position

This position is in the Health Information Management section of the Health Administrative Service at the St. Cloud VA Medical Center in St. Cloud, Minnesota. The Medical Records Technician (Health Information Technician) performs incomplete health record analysis, reviewing, analyzing, abstracting, maintaining, extracting, and compiling information from health records. The technician checks records for accuracy, completeness, and timeliness and monitors and reports regulatory compliance. The incumbent is required to report to and work from the St. Cloud office; telework and virtual work are not available.

The role serves as a technical expert in health record content and documentation requirements. It conducts quantitative and qualitative documentation reviews, supports regulatory reviews and deficiency analysis, and ensures patient-care data in the electronic health record is accurate, timely, and complete. The position also supports compliance with applicable VHA, Joint Commission, CMS, and other regulatory standards, as well as the medico-legal, continuity-of-care, education, and research needs of health records.

Requirements

• Meet the VA basic qualification requirements through one year of creditable experience, a qualifying associate's degree, or an eligible combination of experience and education; qualifying experience must include relevant health-record knowledge and MRT(HIT) skills.
• For GS-5 consideration, meet the applicable experience or education requirements and demonstrate effective customer communication, use of health information technology and office software, knowledge of documentation guidelines, priority management, and application of medical terminology and anatomy.
• For GS-6 consideration, have one year of experience equivalent to the next lower grade and demonstrate efficient health-record navigation, compliance analysis, investigation and correction of potential record errors, application of health information guidelines, and follow-up on incomplete documentation.
• For GS-7 consideration, have one year of experience equivalent to the next lower grade and demonstrate judgment about record sufficiency and accuracy, appropriate action on inadequate records, effective oral and written communication, software skills for analyzing documentation trends, use of assessment methods, independent work, and problem-solving.
• Be a U.S. citizen, except where appointment of a non-citizen is permitted under VA policy.
• Be proficient in written and spoken English.
• Complete the required application steps and online assessment; meet background/security, onboarding, identification, and influenza-vaccination requirements.
• Serve a one- or two-year trial period, subject to written certification for continued employment.

Responsibilities

• Conduct quantitative and qualitative reviews of health record documentation for regulatory reviews and deficiency analysis.
• Ensure patient-care data entered in the electronic health record is accurate, timely, and complete.
• Review health records for compliance with CMS guidelines on student and resident supervision and attending physician presence and documentation; compile provider- and service-specific compliance reports.
• Maintain a control system to ensure inpatient and outpatient health records are completed in accordance with VHA, Joint Commission, CMS, and other regulatory standards.
• 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 and assist with completion of delinquent or incomplete records.
• Assess record completeness, identify and track deficiencies, document them in the appropriate monitoring application, and ensure the appropriate individuals complete them.
• Track electronic signatures and communicate deficiencies to clinical staff through acceptable means, including in person, secure email, or telephone.
• Expedite completion of records for patient transfers to another medical center, legal requests, regulatory reviews, and reimbursement purposes.
• Analyze and resolve filing errors in reports uploaded by a transcription vendor, including identifying the correct patient and filing or assigning the report correctly.
• Generate statistical reports on filing errors, recommend solutions, and implement authorized corrective actions.
• Work with interdisciplinary staff to resolve health record documentation and completion problems; consult clinicians about conflicting or ambiguous documentation.
• Make administrative corrections to health records, including correcting note titles, designating signers or cosigners, and attaching notes to the correct episode of care.
• Use electronic health record functionality to analyze, manage, and monitor documentation and data-capture deficiencies and communicate with staff to resolve them.
• Identify incomplete records for individuals clearing the facility and assist clinicians with the record-clearance process.

Benefits

• Competitive salary with regular salary increases.
• 37–50 days of annual paid time off per year, including 13–26 days of annual leave, 13 days of sick leave, and 11 paid federal holidays.
• Up to 12 weeks of paid parental leave after 12 months of employment, subject to the stated conditions.
• Eligible full-time employees may qualify for a childcare subsidy after 60 days of employment, subject to income and other conditions.
• Traditional federal pension, with five-year vesting, and federal 401(k) with up to 5% in VA contributions.
• Federal health, vision, dental, term life, and long-term care insurance; many federal insurance programs can be carried into retirement.

What This Job Offers

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