MEDICAL RECORDS TECHNICIAN (HEALTH INFORMATION TECHNICIAN)

SelectUSA; Portland (OR); On-site; USD 38,000 - 70,000; Full time

Job summary

A leading company in health information management seeks a Medical Records Technician. This role involves ensuring adherence to documentation regulations, managing health record completion, and performing reviews for compliance. Applicants should have relevant education and experience in medical terminology and health records management.

Qualifications

• U.S. citizenship required.
• Knowledge of medical terminology and health records required.
• Associate's degree or equivalent experience preferred.

Responsibilities

• Perform quantitative and qualitative reviews of health record documentation.
• Ensure compliance with VHA, CMS, and regulatory agency guidelines.
• Prepare reports on status of health records and compliance.

Skills

Medical terminology

Analytical skills

Attention to detail

Education

Associate's degree in health information management

Tools

VISTA

Computerized Patient Record System (CPRS)

Job description

MEDICAL RECORDS TECHNICIAN (HEALTH INFORMATION TECHNICIAN)

MEDICAL RECORDS TECHNICIAN (HEALTH INFORMATION TECHNICIAN)

3 days ago Be among the first 25 applicants

Duties

• Serves as technical expert in health record content and documentation requirements
• Responsible for performing quantitative and qualitative reviews of health record documentation
• Responsible for ensuring that all patient care data entered in VISTA and/or Computerized Patient Record System (CPRS) is accurate, timely, and completed
• Adheres to established documentation requirements as outlined by The Joint Commission regulations, Veterans Health Administration (VHA) guidelines, as well as medical-legal requirements
• Reviews records for adherence with 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 records in accordance with VA, The Joint Commission, CMS and other regulatory agencies standards
• Reviews health records to ensure that all records contain sufficient information to meet medical/legal requirements, to ensure continuity of patient care, and to support education and research needs.
• Assists clinicians with completion of delinquent/incomplete health records.
• Performs the quantitative and qualitative analysis on both computer and paper-based health records.
• Assists physicians with the completion of delinquent/incomplete health records and serves as the expert resource for clinical staff regarding requirements for complete documentation.
• 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.
• Tracks electronic signatures and documents deficiencies and communicates these deficiencies to clinical staff for correction.
• Works independently resolving health record deficiency issues/erroneous documents and corrective action required within CPRS and only seeks guidance of immediate supervisor and/or Clinical Application Coordinator when issues surface when no precedent or procedure has been developed.
• Prepares complex weekly and monthly reports noting the status of all incomplete/delinquent records and compliance reports and submits the reports to the appropriate administrative and clinical staff.
• Reviews health records for adherence with guidelines related to resident supervision and attending physician presence.
• Develops and compiles written reports trending provider specific, service, and hospital compliance reports regarding admission subsequent and discharge notes.
• Obtains statistical information, applies statistical formulas, and completes statistical reports for medical center management.
• Prepares weekly and monthly reports noting the status of all incomplete/delinquent health records and submits the reports to the appropriate administrative and clinical staff.
• Participates in routine and focused reviews for the purpose of identifying problems and potential problems in record documentation as part of the health record review process.
  
  

Help Duties

The duties of this position include but are not limited to the following:

• Serves as technical expert in health record content and documentation requirements
• Responsible for performing quantitative and qualitative reviews of health record documentation
• Responsible for ensuring that all patient care data entered in VISTA and/or Computerized Patient Record System (CPRS) is accurate, timely, and completed
• Adheres to established documentation requirements as outlined by The Joint Commission regulations, Veterans Health Administration (VHA) guidelines, as well as medical-legal requirements
• Reviews records for adherence with 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 records in accordance with VA, The Joint Commission, CMS and other regulatory agencies standards
• Reviews health records to ensure that all records contain sufficient information to meet medical/legal requirements, to ensure continuity of patient care, and to support education and research needs.
• Assists clinicians with completion of delinquent/incomplete health records.
• Performs the quantitative and qualitative analysis on both computer and paper-based health records.
• Assists physicians with the completion of delinquent/incomplete health records and serves as the expert resource for clinical staff regarding requirements for complete documentation.
• 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.
• Tracks electronic signatures and documents deficiencies and communicates these deficiencies to clinical staff for correction.
• Works independently resolving health record deficiency issues/erroneous documents and corrective action required within CPRS and only seeks guidance of immediate supervisor and/or Clinical Application Coordinator when issues surface when no precedent or procedure has been developed.
• Prepares complex weekly and monthly reports noting the status of all incomplete/delinquent records and compliance reports and submits the reports to the appropriate administrative and clinical staff.
• Reviews health records for adherence with guidelines related to resident supervision and attending physician presence.
• Develops and compiles written reports trending provider specific, service, and hospital compliance reports regarding admission subsequent and discharge notes.
• Obtains statistical information, applies statistical formulas, and completes statistical reports for medical center management.
• Prepares weekly and monthly reports noting the status of all incomplete/delinquent health records and submits the reports to the appropriate administrative and clinical staff.
• Participates in routine and focused reviews for the purpose of identifying problems and potential problems in record documentation as part of the health record review process.
  
  

Work Schedule: Monday-Friday, 7:30am to 4:00pm

Compressed/Flexible:Not Authorized

Telework: Not Authorized

Virtual: Not Authorized

Functional Statement #: 000000

Relocation/Recruitment Incentives: Not Authorized

Permanent Change of Station (PCS): Not Authorized

Requirements Conditions of Employment

• You must be a U.S. Citizen to apply for this job.
• Selective Service Registration is required for males born after 12/31/1959.
• Must be proficient in written and spoken English.
• You may be required to serve a probationary period.
• Subject to background/security investigation.
• Selected applicants will be required to complete an online onboarding process.
• Participation in the seasonal influenza vaccination program is a requirement for all Department of Veterans Affairs Health Care Personnel (HCP).
  
  

Qualifications

Basic Requirements:

Citizenship: Citizen of the United States. (Non-citizens may be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy.

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, 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:

• 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.
• 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.
• 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.
  
  

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).
  
  

Grade Determinations

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

• Experience or Education. None beyond basic requirements.
• Assignment. Employees at this level serve as entry level MRTs HIT, and receive close supervision from the supervisory MRT HIT or designee.
  
  

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).
• Assignment. Employees at this grade level serve in developmental positions as MRTs HIT. 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-6

• Experience. One year of experience equivalent to the next lower grade level.
• Assignment. This is a developmental level for MRT HIT.
• 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)

• Experience. One year of experience equivalent to the next lower grade level.
• Assignment. This is considered the journey level for MRTs HIT.
• 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.
  
  

Preferred Experience: RHIT certification (CPC, RHIT, RHIA CPC or RHIA) preferred. Per National VHA Directive 1907.01(1) 12/11/2023; HIM professionals are highly trained in the latest information management technology applications. HIM professionals are vital to the daily operations management of health information and health records and ensure the quality and accuracy.

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-4. The actual grade at which an applicant may be selected for this vacancy is in the range of GS-4 to GS-7.

Education

IMPORTANT: A transcript must be submitted with your application if you are basing all or part of your qualifications on education.

Note: Only education or degrees recognized by the U.S. Department of Education from accredited colleges, universities, schools, or institutions may be used to qualify for Federal employment. You can verify your education here: http://ope.ed.gov/accreditation/ . If you are using foreign education to meet qualification requirements, you must send a Certificate of Foreign Equivalency with your transcript in order to receive credit for that education. For further information, visit: https://sites.ed.gov/international/recognition-of-foreign-qualifications/ .

Additional Information

During the application process you may have an option to opt-in to make your resume available to hiring managers in the agency who have similar positions. Opting in does not impact your application for this announcement, nor does it guarantee further consideration for additional positions.

This job opportunity announcement may be used to fill additional vacancies.

This position is in the Excepted Service and does not confer competitive status.

VA encourages persons with disabilities to apply. The health-related positions in VA are covered by Title 38, and are not covered by the Schedule A excepted appointment authority.

If you are unable to apply online or need an alternate method to submit documents, please reach out to the Agency Contact listed in this Job Opportunity Announcement.

Under the Fair Chance to Compete Act, the Department of Veterans Affairs prohibits requesting an applicant's criminal history prior to accepting a tentative job offer. For more information about the Act and the complaint process, visit Human Resources and Administration/Operations, Security, and Preparedness (HRA/OSP) at The Fair Chance Act .

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Seniority level

• Seniority level

  Entry level

Employment type

• Employment type

  Full-time

Job function

• Job function

  Health Care Provider

• Industries

  International Trade and Development

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