Medical Records Technician (HIT)
About The Position
This position is located in the Health Information Management (HIM) Section. The Medical Records Technician (HIT) performs incomplete health record analysis and reviews, analyzes, abstracts, maintains, extracts, and compiles information from health records. The role checks records for accuracy, completeness, timeliness, consistency, and regulatory compliance, including verifying that records are scanned or uploaded correctly, use appropriate titles, and are linked to the correct encounters. The technician coordinates or performs health record reviews to meet external accreditation requirements and medical center performance measures. The position communicates with staff at various organizational levels about delinquent records and notifies clinical providers about incomplete documentation. It prepares complex reports and department statistics, tracks incomplete or delinquent records, and submits reports to appropriate staff, committees, and leadership to help ensure deficiencies are resolved. The technician serves as a resource for clinical staff and assists providers with completing or correcting health record documentation. Duties also include reviewing incomplete records for individuals clearing the facility and coordinating the use of medical speech recognition/AI technology, including monitoring, verifying, and troubleshooting licenses to maintain record completeness and accuracy. The position is a technical resource on health record content and documentation requirements. The schedule is full-time, Monday through Friday, 8:00 a.m. to 4:30 p.m. (negotiable). The position is not virtual and does not offer telework.
Requirements
- U.S. citizenship, subject to the stated exception for appointments when qualified citizens cannot be recruited.
- Proficiency in written and spoken English.
- Meet the basic experience or education requirements through one of the specified pathways: one year of creditable experience (including six months providing MRT HIT KSAs); a qualifying associate degree; or an equivalent combination of experience and education.
- For GS-5 through GS-7, meet the applicable grade-level experience or education requirements and demonstrate the listed knowledge, skills, and abilities for that grade.
- GS-5 KSAs include effective communication; use of health information technology and office software; knowledge of health record documentation guidelines and industry standards; prioritization and coordination of work; and application of medical terminology and anatomy knowledge.
- GS-6 KSAs include efficient navigation of health records; analysis of documentation for compliance; investigation of potential errors and correction when appropriate; interpretation and application of health information guidelines; and follow-up on incomplete documentation.
- GS-7 KSAs include judging whether records meet regulatory, legal, patient-care, education, and research needs; taking appropriate action when content is inadequate or unreliable; oral and written communication to facilitate compliance; using software to analyze and record documentation trends; applying qualitative or quantitative assessment methods; and working independently with problem-solving techniques.
- Submit transcripts when using education to qualify; only education from appropriately accredited institutions recognized by the U.S. Department of Education may be used.
- Selected applicants must complete required application steps, an online onboarding process, and a background/security investigation; acceptable identification is required for pre-employment requirements.
- Males born after December 31, 1959, must meet Selective Service registration requirements.
- Participation in the seasonal influenza vaccination program is required for VA Health Care Personnel.
- Serve a one- or two-year trial period, subject to written certification for continued employment.
Nice To Haves
- Knowledge of medical terminology, anatomy, physiology, and a general understanding of health records.
- Experience analyzing health records for accuracy, completeness, timeliness, consistency, and compliance.
- Strong communication skills and the ability to speak courteously, tactfully, and respectfully.
Responsibilities
- Review, analyze, abstract, maintain, extract, and compile health record information independently with minimal supervision.
- Analyze health records for accuracy, completeness, timeliness, consistency, and compliance.
- Coordinate or perform health record reviews to meet external accreditation requirements and medical center performance measures.
- Communicate with staff about delinquent health records and notify clinical providers about incomplete records.
- Prepare complex reports and calculate department statistics; track incomplete and delinquent records and submit reports to appropriate staff, committees, and leadership.
- Serve as an expert resource for clinical staff and assist providers with completing or correcting health record documentation.
- Review incomplete records for individuals clearing the facility.
- Coordinate the use of medical speech recognition/AI technology and monitor, verify, and troubleshoot related licenses.
- Serve as a technical expert on health record content and documentation requirements.
Benefits
- Federal employee benefits package; the specific benefits offered depend on position type and should be confirmed with the hiring agency.
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What This Job Offers
Job Type
Full-time
Career Level
Entry Level
Education Level
Associate degree
