Medical Records Technician (Health Information Technician)

Veterans Health Administration • Minneapolis, MN

6d • Onsite

About The Position

This position serves as a Medical Records Technician—Health Information Technician (MRT-HIT), analyzing, abstracting, maintaining, extracting, and compiling information from health records under supervisory review. The incumbent performs complex health information functions, including web-based programs, and uses health information technology and office software to support health information management activities. The full performance level is GS-7; selection may be made at GS-4 through GS-7.

The role performs quantitative and qualitative reviews of health record documentation and ensures patient-care data entered in VistA and/or the Computerized Patient Record System (CPRS) is accurate, timely, and complete. Work must comply with Joint Commission regulations, Veterans Health Administration guidance, CMS guidance, and medical-legal requirements. The technician identifies, tracks, documents, and follows up on deficiencies in paper and electronic health records, assists physicians with delinquent or incomplete records, and advises clinical staff about complete-documentation requirements.

The incumbent independently resolves record-deficiency issues and erroneous documents, making corrections or seeking management guidance for particularly challenging or complex issues. The technician prepares status, compliance, statistical, and trend reports; performs analytical work to resolve documentation errors such as incorrect patient, appointment, title, or consult entries; and analyzes and compiles health-record information for internal and external studies and audits. The position uses systems and products such as electronic health records and exchanges, office software, electronic databases, HIMS software, Patient Treatment File, Patient Care Encounter, and voice-recognition, transcription, and dictation systems. The work schedule is 7:00 a.m. to 3:30 p.m., with the tour of duty negotiable. Telework and virtual work are not available.

Requirements

• Meet the basic experience and education requirements through one of the stated routes: one year of creditable experience indicating knowledge of medical terminology, anatomy, physiology, and health records, including six months providing MRT-HIT knowledge, skills, and abilities; an associate's degree in health information technology/management or a related degree with at least 12 semester hours in the field; or an eligible combination of experience and education.
• For the experience-and-education combination route, qualifying military or maritime medical technician, hospital corpsman, medical service specialist, or hospital training may substitute for up to six months of experience when the stated coursework and training conditions are met.
• Be proficient in spoken and written English.
• Meet the grade-specific experience or education requirements for the grade sought. GS-5 through GS-7 require one year of experience equivalent to the next lower grade, with the specified alternative bachelor's-degree route available for GS-5.
• Demonstrate grade-specific knowledge, skills, and abilities, including effective communication; use of health information technology and office software; knowledge of documentation guidelines and industry standards; prioritization and timely completion; medical terminology and anatomy; efficient record navigation; documentation analysis and error investigation; application of health information guidelines; follow-up on incomplete documentation; assessment of record adequacy and accuracy; software-based trend analysis; qualitative or quantitative assessment; and independent problem solving.
• Be a U.S. citizen, subject to the stated exception for non-citizen appointments when qualified citizens cannot be recruited under VA policy.
• Meet applicable pre-employment, identity-verification, background/security, onboarding, and seasonal influenza vaccination requirements.
• Male applicants born after December 31, 1959, must be registered with Selective Service.
• Serve the required one- or two-year trial period, subject to the stated continuation certification process.

Nice To Haves

• Health-record review experience.
• Encounter-correction experience.
• Chart-preparation experience.

Responsibilities

• Perform quantitative and qualitative reviews of health-record documentation.
• Ensure patient-care data entered in VistA and/or CPRS is accurate, timely, and complete, in accordance with applicable documentation requirements.
• Identify, track, and record deficiencies in paper and electronic health records, and follow up to ensure the appropriate individual completes them.
• Assist physicians with delinquent or incomplete health records and advise clinical staff on complete-documentation requirements.
• Independently resolve record-deficiency issues and erroneous documents, including making appropriate corrections in CPRS; seek management guidance on challenging or complex issues.
• Prepare reports on incomplete or delinquent records and compliance, and submit reports to committees and staff.
• Analyze and resolve documentation errors, including incorrect patient, appointment, title, and consult entries, and reassign entries as appropriate.
• Generate statistical reports to track errors and compile reports on provider-, service-, and hospital-specific compliance trends related to admission, subsequent, and discharge notes.
• Analyze, abstract, maintain, extract, and compile health-record information for internal and external studies and audits.
• Use health information technology, office software, databases, and health information management systems to perform complex health information functions.
• Manage priorities, coordinate work to meet required timeframes, and follow up on pending issues.
• Perform other duties as assigned.

Benefits

• Competitive salary and 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.
• Potential credit toward annual-leave accrual based on prior work or military service, subject to approval.
• Up to 12 weeks of paid parental leave after 12 months of employment, in connection with birth, adoption, or foster-care placement.
• Potential childcare subsidy after 60 days for eligible full-time employees and families meeting the stated income and eligibility conditions.
• Traditional federal pension with five-year vesting and federal 401(k) with up to 5% in contributions by VA.
• Federal health, vision, dental, term life, and long-term-care insurance; many programs may be carried into retirement.

What This Job Offers

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