Medical Records Technician (Health Information Technician)

US-Department-of-Veterans-Affair; Baltimore (MD); On-site; USD 42,000 - 66,000; Full time

Job summary

The U.S. Department of Veterans Affairs is seeking a Medical Records Technician (Health Information Technician) to join the Health Information Management (HIM) section at the VA Maryland Healthcare Center.

This role involves performing incomplete health record analysis and ensuring records meet regulatory standards. Candidates should have the required education or experience as outlined, including knowledge of medical terminology, anatomy, and health record guidelines.

Qualifications

• Associate's degree or higher in health information management or related field with specific health IT coursework.
• Bachelor's degree with 24 credit hours in HIT/HIM qualifies.
• Equivalent combinations of education and experience may apply as described in the job posting.

Responsibilities

• Analyze incomplete health records to ensure compliance with guidelines.
• Apply knowledge of medical terminology and anatomy to health records.
• Utilize health information technology and office software to track and improve records.
• Coordinate priorities and complete duties within required timeframes.

Skills

Medical terminology

Anatomy

Physiology

Communication skills

Time management

Education

Associate's degree in health information technology/health information management

Bachelor's degree in health information management or related with 24 semester hours in health information technology/health information management

Tools

Microsoft Excel

Electronic Health Records

Delinquency tracking software

Job description

CRITICAL Shortage LIST OIG: 38 U.S.C. 7412 waives the requirement to apply Veterans' preference to external applicants for appointments made during the fiscal year to hybrid title 38 occupations among those reported to have the largest staffing shortages.

This position is located in the Health Information Management (HIM) section at the VA Maryland Healthcare Center. Medical Records Technician (Health Information Technician) perform incomplete health record analysis. Applicants pending the completion of educational or certification/licensure requirements may be referred and tentatively selected but may not be hired until all requirements are met.

Basic Requirements

• United States Citizenship:

Non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy.

• Experience and Education:

Experience. One year of creditable experience that indicates knowledge of medical terminology, anatomy, physiology, and a general understanding of health records. Six months of the required one year of creditable experience must have provided the knowledge, skills, and abilities (KSAs) needed to perform MRT HIT work.

OR

Education.

An associate's degree from an accredited college or university recognized by the U.S. Department of Education, with a major field of study in health information technology/health information management, or a related degree with a minimum of 12 semester hours in health information technology/health information management (e.g., courses in medical terminology, anatomy, physiology, legal aspects of health care, and introduction to health records).

OR

Experience/Education Combination. Equivalent combinations of creditable experience and education are qualifying towards meeting basic experience requirements. The following educational/training substitutions are appropriate for combining education and creditable experience:

(a) Six months of creditable experience that indicates knowledge of medical terminology, privacy and release of information, the health record, and one year above high school with a minimum of six semester hours of health information technology/health information management.

(b) Six months of creditable experience that indicates knowledge of medical terminology, privacy and release of information, the health record, and successful completion of a course for medical technicians, hospital corpsmen, medical service specialists, or hospital training obtained in a training program given by the U.S. Armed Forces or the U.S. Maritime Service, under close medical and professional supervision, may be substituted on a month-for-month basis for up to six months of experience, provided the training program included courses in anatomy, physiology, and health record techniques and procedures.

• Physical Requirements:

See VA Directive and Handbook 5019, Employee Occupational Health Service.

• English Language Proficiency:

MRTs HIT must be proficient in spoken and written English, as required by 38 U.S.C. § 7403(f).

May qualify based on being covered by the Grandfathering Provision as described in the VA Qualification Standard for this occupation (only applicable to current VHA employees who are in this occupation and meet the criteria).

Grade Determinations

Medical Records Technician (HIT), GS-4 (Entry Level)

• Experience or Education. None beyond basic requirements

Medical Records Technician (HIT), GS-5 (Developmental Level 1)

• Experience. One year of experience equivalent to the next lower level.

OR

• Education. A bachelor's degree from an accredited college or university recognized by the U.S. Department of Education with a major field of study in health information management, or a related degree with a minimum of 24 semester hours in health information technology/health information management (e.g., courses in medical terminology, anatomy & physiology, legal aspects of health care, and introduction to health records).

AND

• Demonstrated Knowledge, Skills, and Abilities. In addition to the experience above, the candidate must demonstrate all of the following KSAs:

(a) Ability to communicate effectively with internal and external customers.

(b) Ability to utilize health information technology and various office software products used in health information management positions (e.g., Microsoft Excel, electronic health records, and delinquency tracking software).

(c) Knowledge of health record documentation guidelines and industry standards.

(d) Ability to manage priorities and coordinate work to complete duties within required timeframes.

(e) Ability to apply knowledge of medical terminology and human anatomy to fully understand the content of a health record.

Medical Records Technician (HIT), GS-6

• Experience. One year of experience equivalent to the next lower grade level.

AND

• Demonstrated Knowledge, Skills, and Abilities. In addition to the experience above, the candidate must demonstrate all of the following KSAs:

(a) Ability to navigate efficiently through the health record to locate needed information.

(b) Ability to analyze health record documentation to ensure compliance with guidelines and industry standards.

(c) Skill in investigating potential health record errors and making corrections, when appropriate.

(d) Skill in interpreting and applying health information guidelines and using judgment to complete assignments.

(e) Ability to follow up on incomplete health record documentation.

Medical Records Technician (HIT), GS-7 (Full Performance Level)

• Experience. One year of experience equivalent to the next lower grade level.

AND

• Demonstrated Knowledge, Skills, and Abilities. In addition to the experience above, the candidate must demonstrate all of the following KSAs:

(a) Ability to judge whether health records contain sufficient information for regulatory requirements, are acceptable as legal documents, are adequate for continuity of patient care, and support education and research needs.

(b) Ability to take appropriate actions if health record content is not adequate, accurate, timely, and/or reliable.

(c) Ability to communicate both orally and in writing with individuals or groups, to facilitate compliance with established policies and regulations.

(d) Skill in using appropriate software and computer applications to analyze and record documentation trends.

(e) Ability to apply qualitative and/or quantitative methods for assessment and improvement of health records.

(f) Ability to work independently and utilize problem-solving techniques in the accomplishment of work.

Preferred Experience: None

Reference: For more information on this qualification standard, please visit https://www.va.gov/ohrm/QualificationStandards/.

The full performance level of this vacancy is GS-07. The actual grade at which an applicant may be selected for this vacancy is in the range of GS-04 to GS-07.

Physical Requirements: See VA Directive and Handbook 5019, Employee Occupational Health Service.