Medical Records Technician (HIT)

U.S. Department of Veterans Affairs; Fresno (CA); On-site; USD 40,000 - 70,000; Full time

Job summary

The U.S. Department of Veterans Affairs in Fresno, CA, seeks Medical Records Technician (HIT) within the Health Information Management (HIM) section at VACCHCS. HITs review, analyze, abstract, maintain and extract information from health records, ensuring accuracy and regulatory compliance.

Responsibilities include health record completeness checks, submission of reports, and collaboration with clinical staff to manage documentation workflows and support accreditation efforts.

Qualifications

• US citizenship is required; non-citizens may be appointed per VA policy
• English language proficiency required for MRT HIT
• Experience or education in health information management or medical terminology is required

Responsibilities

• Prepare lists of paper health records for signature and completion
• Monitor delinquent dictation and ensure necessary documents are completed
• Notify physicians and staff about the status of dictation and incomplete records
• Perform health information management program support in Transcription and Incomplete Medical Records
• Generate weekly/monthly reports on incomplete/delinquent records and compliance

Skills

Medical terminology

Anatomy

Physiology

Health records

English proficiency

Education

Associate degree in HIT

Bachelor's degree in HIT

Job description

Summary

This position is located in the Health Information Management (HIM) section at the VA Central California Health Care System (VACCHCS). The Medical Records Technician (MRT) Health Information Technicians - (HITs) review - analyze - abstract - compile - maintain - and extract information from the health record. They also check for completeness and accuracy 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 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
• Grade Determinations: In addition to the Basic Requirements - you must meet the following: GS-4 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
• MRTs HIT 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 accrediting bodies
• They perform health record review activities to satisfy external accreditation requirements and medical center performance measures
• They monitor - verify - correct - and upload all transcription/medical speech recognition to maintain completeness and accuracy of health records.GS-5Experience
• 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
• Employees receive guidance from the supervisory MRT HIT - or designee - for more complex health record reviews
• See VA Handbook PART II APPENDIX G59
• 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
• GS-6 Experience
• One year of experience equivalent to the next lower grade level
• Assignment
• This is a developmental level for MRT HIT
• The MRT HIT at this level receives guidance from the supervisory MRT HIT - or designee - for more complex health records
• 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 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
• See VA Handbook PART II APPENDIX G59
• 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
• GS-7 Experience
• One year of experience equivalent to the next lower grade level
• Assignment
• This is considered the journey level for MRTs HIT
• MRTs HIT at this level 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
• They also coordinate and/or perform health record review activities to satisfy external accreditation requirements and medical center performance measures
• They communicate regularly with staff at various levels of the organization regarding delinquent health records - and notify individual clinical providers regarding incomplete medical records
• See VA Handbook PART II APPENDIX G59
• 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.

Duties

• Duties include but are not limited to: Preparing lists of paper health records needed for signature(s) that are located in the incomplete record area for distribution to appropriate service lines (i.e. - Medicine - Surgery - Psychiatry - etc.) or that are not complete in the electronic health record
• Monitors delinquent dictation list for follow up purposes on necessary documents (i.e. - operation reports - discharge summaries - etc.) that are needed for completion of health records
• Notifies appropriate physician and other personnel of the status of dictation
• Monitors house-staff rotation schedule and contacts resident house-staff to ensure completion of records prior to departure from the Medical Center
• Utilizes basic knowledge of medical terminology - anatomy and physiology - and coding to research and collect information for various medical studies and research projects utilizing the Patient Treatment File (PTF) and PTF microfiche
• Participates in approved quality improvement focused reviews
• Coordinates review activities with the Quality Improvement Program to satisfy external accreditation requirements - and to satisfy current Medical Center performance measures
• Preforms 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 reviews - verifies - and corrects all statistical data concerning medical transcription to maintain accuracy of medical and statistical reports
• Performs clerical or technical program support work for the Incomplete Records/Transcription Unit in support of the Health Information Management program of this facility
• Performs program support functions for Health Information Management in the areas of Transcription and Incomplete Medical Records
• Performs general program support work such as the collection - compilation - research - and/or tracking of data and program information
• This includes - but is not limited to - determining which reports need to be dictated and/or signed by the clinician - identifying physicians with delinquent medical records - identifying which dictated reports have been returned and completed by the transcription vendor
• Tracks electronic signatures and documents deficiencies and communicates these deficiencies to clinical staff for correction
• Notification can be in person - internal e-mail - telephone - or through other normal routing system
• Works independently resolving 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
• 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
• Duties may also include the generation of various statistical reports to track these errors
• Makes appropriate recommendations for changes or solutions and facilitate appropriate recommendations for corrective action when authorized so continued filing errors do not occur
• The Medical Records Technician serves as technical expert in health record content and documentation requirements
• Medical Records Technician is responsible for performing quantitative and qualitative reviews of health record documentation
• Medical Records Technician is 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
• Other duties as assigned
• Duties may slightly differ depending on grade level you are selected at
• Work Schedule: Monday-Friday 8:00am-4:30pm or as determined by supervisor
• Functional Statement #: 09388-F Relocation/Recruitment Incentives: Not authorized Permanent Change of Station (PCS): Not authorized.