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 supervisor review. The technician 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 guidelines, Centers for Medicare & Medicaid Services guidance, and medical-legal requirements.

The position identifies, tracks, and records deficiencies in paper and electronic health records and follows up to ensure they are completed. The technician assists physicians with delinquent or incomplete records, advises clinical staff on documentation requirements, resolves routine record-deficiency issues and erroneous documents independently, and seeks management guidance for more complex issues. The technician prepares status, compliance, and trend reports for committees and staff; investigates and corrects documentation errors such as wrong-patient, appointment, title, or consult entries; and may generate statistical reports to track errors.

The role also supports special studies and internal and external audits by analyzing, abstracting, maintaining, extracting, and compiling health-record information. It uses health information technology and office software, including electronic health records and exchanges, office products, databases, HIMS systems, Patient Treatment File (PTF), Patient Care Encounter (PCE), voice-recognition systems, and transcription and dictation systems. The position performs complex health-information functions, including web-based programs, and requires the ability to manage priorities, meet deadlines, and follow up on pending issues.

The work schedule is 7:00 a.m. to 3:30 p.m.; the tour of duty may be negotiable. Telework is not available, and the position is not virtual. The full-performance level is GS-7, and the vacancy may be filled at GS-4 through GS-7. The position is in the Excepted Service and does not confer competitive status.

Requirements

• Meet the basic qualification through one year of creditable experience indicating knowledge of medical terminology, anatomy, physiology, and general health records, including at least six months providing the KSAs needed for MRT-HIT work; or an eligible associate's degree; or an allowed combination of education and experience.
• An eligible associate's degree must be from an accredited institution and have a major in health information technology/health information management, or a related degree with at least 12 semester hours in health information technology/health information management.
• Eligible combinations may include qualifying military or maritime medical training, with the specified coursework and experience substitution described in the announcement.
• Be a U.S. citizen, subject to the stated exception for non-citizens when qualified citizens cannot be recruited under VA policy.
• Be proficient in spoken and written English.
• Meet the grade-specific experience or education and demonstrated knowledge, skills, and abilities for the grade sought. GS-5 through GS-7 require one year of experience at the next lower grade or the specified qualifying education where applicable.
• Communicate effectively with internal and external customers; use health-information technology and office software; understand health-record documentation guidelines; manage priorities and deadlines; and apply medical terminology and human anatomy knowledge, as applicable to grade requirements.
• Navigate health records, analyze documentation for compliance, investigate potential errors and make corrections when appropriate, interpret and apply health-information guidelines, and follow up on incomplete documentation, as applicable to grade requirements.
• At the GS-7 full-performance level, judge whether records meet regulatory, legal, continuity-of-care, education, and research needs; take appropriate action when records are inadequate, inaccurate, untimely, or unreliable; communicate policies and requirements orally and in writing; use software to analyze and record trends; apply qualitative or quantitative assessment methods; and work independently using problem-solving techniques.
• Complete required background/security investigation, online onboarding, and pre-employment requirements, including acceptable identification and participation in the seasonal influenza vaccination program.
• Serve a one- or two-year trial period, subject to evaluation and written certification for continued employment.
• Meet physical requirements referenced in VA Directive and Handbook 5019 and participate in a pre-employment examination or evaluation.

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.
• Apply Joint Commission regulations, VHA guidelines, CMS guidance, and medical-legal requirements to health-record documentation.
• 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 about complete-documentation requirements.
• Resolve routine record-deficiency issues and erroneous documents independently, seeking management guidance for challenging or complex issues.
• Prepare reports on incomplete and delinquent records and compliance, and submit reports to committees and staff.
• Analyze and resolve documentation errors, including incorrect patient, appointment, title, or consult entries, and reassign or correct them as appropriate.
• Generate statistical reports to track errors when required.
• Develop and compile provider-, service-, and hospital-specific compliance and trend reports concerning admission, subsequent, and discharge notes.
• Analyze, abstract, maintain, extract, and compile health-record information for special studies and internal and external audits.
• Use health information technology, office software, databases, HIMS systems, and other health-record and documentation applications to perform complex functions, including web-based work.
• Manage priorities, coordinate work to meet required timeframes, and follow up on pending issues.
• Perform other duties as assigned.

Benefits

• The announcement states that federal employees and their families have access to a comprehensive benefits package; specific benefits depend on position eligibility and should be confirmed with the hiring agency.

What This Job Offers

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