Medical Records Technician (Health Information Technician)

US-Department-of-Veterans-Affair; Cape Coral (FL); On-site; USD 42,000 - 66,000; Full time

Job summary

Bay Pines VA Healthcare System (BPVAHCS) is seeking a Medical Records Technician (HIT) to analyze and manage health records. The MRT HIT will review, abstract, maintain, extract, and compile information from health records, ensuring accuracy, completeness, and timeliness for regulatory compliance.

The role requires knowledge of medical terminology, anatomy, and health information practices, with stated basic and advanced grade levels and potential education substitutions as described by VA

Qualifications

• One year of creditable experience showing knowledge of medical terminology, anatomy, physiology, and health records.
• An associate's degree with 12 semester hours in health information technology/health information management or related.
• Equivalent combinations of creditable experience and education are acceptable for meeting basic requirements.
• Six months of creditable experience with six months of HIM coursework may substitute for six months of experience.

Responsibilities

• Analyze health records for accuracy, completeness, timeliness, and regulatory compliance.
• Coordinate and perform health record review activities.
• Notify clinical providers regarding incomplete health records.
• Create and monitor reports; monitor transcription/medical speech recognition.
• Apply knowledge of medical terminology and anatomy to health records.

Skills

Communication

Health IT

Excel

Documentation standards

Prioritization

Medical terminology

Anatomy knowledge

Education

Associate degree in HIM

Bachelor’s in HIM

Tools

EHR systems

Delinquency tracking software

Microsoft Excel

Job description

This position is located in the Health Information Management (HIM) section of the Business Office at the Bay Pines VA Healthcare System (BPVAHCS). Medical Record Technician (MRTs) Health Information Technician (HIT) perform incomplete health record analysis. They review, analyze, abstract, maintain, extract, and compile information from the health record. MRTs HIT check for accuracy, completeness, and timeliness of the health record and monitor and report for regulatory compliance.

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

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:

• 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.
• 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.

Grandfathering Provision

All persons employed in VHA as a MRT HIT, on the effective date of this qualification standard, are considered to have met all qualification requirements for the grade held, including positive education and licensure/certification/ registration that are part of the basic requirements of the occupation. For employees who do not meet all the basic requirements in this standard, but who met the qualifications applicable to the position at the time they were appointed to it, the following provisions apply: (1) Such employees in an occupation that does not require a licensure/certification/ registration, may be reassigned, promoted, or demoted within the occupation, but will not be promoted beyond the journey level or placed in supervisory or managerial positions. (2) Employees appointed on a temporary basis prior to the effective date of the qualification standard may not have their temporary appointment extended, or be reappointed on a temporary or permanent basis, until they fully meet the basic requirements of the standard. (3) Employees initially grandfathered into this occupation, who subsequently obtain additional education and/or licensure/certification/registration that meet all the basic requirements of this qualification standard, must maintain the required credentials, as a condition of employment in the occupation.

Grade Determinations

Medical Records Technician (HIT), GS-675-4 (Entry Level).

None beyond basic requirements. Assignments: MRTs HIT analyze health records.

Medical Records Technician (HIT), GS-675-5 (Developmental Level 1)

One year of experience equivalent to the next lower level, GS-675-04. Assignments: MRTs HIT analyze health records. Create and monitor reports. Monitor all transcription/medical speech recognition. MRTs HIT notify clinical providers regarding incomplete health records.

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).

Demonstrated Knowledge, Skills, and Abilities.

• Ability to communicate effectively with internal and external customers.
• 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).
• Knowledge of health record documentation guidelines and industry standards.
• Ability to manage priorities and coordinate work to complete duties within required timeframes.
• Ability to apply knowledge of medical terminology and human anatomy to fully understand the content of a health record.

Medical Records Technician (HIT), GS-675-06

One year of experience equivalent to the next lower grade level, GS-05. Assignments: The MRT HIT analyzes, abstracts, maintains, extracts and compiles information from the health record, working under the review of the supervisor. They analyze health records. Coordinate and/or perform health record review activities.

Demonstrated Knowledge, Skills, and Abilities.

• Ability to navigate efficiently through the health record to locate needed information.
• Ability to analyze health record documentation to ensure compliance with guidelines and industry standards.
• Skill in investigating potential health record errors and making corrections, when appropriate.
• Skill in interpreting and applying health information guidelines and using judgment to complete assignments.
• Ability to follow up on incomplete health record documentation.

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

one year of experience equivalent to the next lower grade level, GS-675-06. Assignments: Analyze health records for accuracy, completeness, timeliness, consistency, and compliance. Coordinate and/or perform health record review.

Demonstrated Knowledge, Skills, and Abilities.

• 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.
• Ability to take appropriate actions if health record content is not adequate, accurate, timely, and/or reliable.
• Ability to communicate both orally and in writing with individuals or groups, to facilitate compliance with established policies and regulations.
• Skill in using appropriate software and computer applications to analyze and record documentation trends.
• Ability to apply qualitative and/or quantitative methods for assessment and improvement of health records.
• Ability to work independently and utilize problem-solving techniques in the accomplishment of work.

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-7. The actual grade at which an applicant may be selected for this vacancy is in the range of GS-04 to GS-7.

Physical Requirements

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