Medical Records Technician (Health Information Technician)

U.S. Department of Veterans Affairs; Cape Coral (FL); On-site; USD 42,000 - 64,000; Full time

Job summary

Bay Pines VA Healthcare System is seeking a Medical Records Technician (Health Information Technician) to analyze, abstract, maintain, extract and compile information from health records. The role ensures accuracy, completeness, and timeliness of records in accordance with VHA guidelines and regulatory requirements.

The MRT HIT will review health records, monitor compliance, and coordinate with clinical staff to resolve deficiencies, supporting education, research, and patient care continuity.

Qualifications

• Knowledge of medical terminology, anatomy, physiology and health records.
• Experience or education combining health information knowledge and records management.

Responsibilities

• Analyze health records for accuracy, completeness, timeliness and compliance.
• Notify clinicians about missing or incomplete documentation.
• Create, monitor and coordinate health record review activities.
• Ensure health records are accurate, timely and complete in the EHR.

Skills

Medical terminology

Anatomy

Physiology

Health records

Education

Associate degree in health information technology/health information management

Bachelor's degree with 24 semester hours in health information management

Job description

Summary

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.

Qualifications

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


• In addition to the experience above - the candidate must demonstrate all of the following KSAs: 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


• In addition to the experience above - the candidate must demonstrate all of the following KSAs: 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


• In addition to the experience above - the candidate must demonstrate all of the following KSAs: 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.

Duties

• The closing date has been extended and will now close on October 13 - 2026


• Total Rewards of a Allied Health Professional Medical Records Technician (Health Information Technician) review - analyze - abstract - maintain - extract - and compile information from the health record independently with minimal supervision


• They analyze health records for accuracy - completeness - timeliness - consistency - and compliance (e.g. - scanned - uploaded - use of correct titles - linked to correct encounters - etc.) with HIM industry standards - policies - procedures - laws - regulations - and accreditation requirements


• Medical Record Technician duties and responsibilities include but are not limited to: Serves as technical expert in health record content and documentation requirements


• Responsible for performing quantitative and qualitative reviews of health record documentation for ongoing regulatory reviews and deficiency analysis


• Ensures that all patient care data entered in the electronic health record (EHR) is accurate - timely - and complete


• Adheres to established documentation requirements as outlined by The Joint Commission (TJC) regulations - Veterans Health Administration (VHA) guidelines - as well as medico-legal requirements


• Reviews health records for adherence with the Centers for Medicare and Medicaid Services (CMS) guidelines related to student - resident supervision and attending physician presence and documentation


• Compiles reports to insure provider specific and service compliance


• Maintains a control system to ensure completion of all inpatient and outpatient health records in accordance with VHA - TJC - CMS and other regulatory agencies standards


• Reviews health records to ensure that all health records contain sufficient information to meet medico-legal requirements - to ensure continuity of patient care - and to support education and research needs


• Notifies clinicians of missing - incomplete - or inaccurate information in their signature blocks (e.g. - missing or inaccurate credentials)


• Assists clinicians with completion of delinquent/incomplete health records


• Assesses the health record for completeness - identifies health record deficiencies - tracks deficiencies - and ensures that the appropriate individuals complete their deficiencies


• Tracks unsigned/uncosigned notes (e.g. - progress notes - operative reports - discharge summaries - etc.) and encounters without associated progress notes - and communicates these deficiencies to clinical staff for completion


• Responsible for expediting the completion of the health record when the patient is transferred for care at another medical center - for legal requests - regulatory agencies review - and reimbursement purposes


• Performs analytical tasks associated with the resolution of \"filing\" errors on reports uploaded by a transcription vendor


• This includes correctly identifying the patient the report belongs to and filing/assigning it correctly


• Identifies any blanks in transcribed documentation and takes appropriate action to track deficiencies - when required by local workflows - and follows up with the responsible provider for correction


• Identifies reviews - verifies - and corrects all statistical data concerning medical transcription to maintain accuracy of medical and statistical reports


• Compares and resolves discrepancies between reports of admission - discharge - transfers and all outpatient and ambulatory services with contract transcription logs as it relates to timeliness and accuracy of dictated reports completed by medical transcription contractor


• Work Schedule: Monday through Friday from 8:00am to 4:30pm Telework: Not Authorized Virtual: This is not a virtual position


• Functional Statement #: 32056F - 32055F - 32054F - 32053F Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized PCS Appraised Value Offer (AVO): Not Authorized