Medical Records Technician (HIT)

US-Department-of-Veterans-Affair; Manchester (NH); On-site; USD 42,000 - 62,000; Full time

Job summary

US Department of Veterans Affairs is seeking a Medical Records Technician (HIT) at the Manchester VA Medical Center in Manchester, NH. This is a full-time, 40-hour per week position within the Business Office service.

The role progresses from entry-level MRT HIT GS-4 to full-performance GS-7, with duties including health record analysis, guidance to clinical staff on completeness, and coordination of health record reviews to meet accreditation standards.

Qualifications

• One year of creditable experience that indicates knowledge of medical terminology, anatomy, physiology.
• Six months of the required one year must have provided the KSAs needed to perform MRT HIT work.
• Associate's degree with 12 semester hours in health information technology/health information management or related field.

Responsibilities

• Analyze health records for accuracy, timeliness, consistency, and compliance with HIM standards.
• Notify clinical providers regarding incomplete health records and assist with documentation.
• Coordinate and/or perform health record review activities to meet external accreditation requirements.

Skills

Communication

Health information tech

Health record guidelines

Prioritization

Medical terminology/anatomy

Education

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

Tools

Microsoft Excel

Electronic health records

Delinquency tracking software

Job description

This Medical Records Technician (HIT) position is in Business Office service at the Manchester VA Medical Center, located in Manchester NH. This position is a full-time at 40 hours per week.

Basic Requirements

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.

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).

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:

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. 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.

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. Employees receive guidance from the supervisory MRT HIT, or designee, for more complex health record reviews. They perform health record review activities to satisfy external accreditation requirements and medical center performance measures. MRTs HIT notify clinical providers regarding incomplete health records, and assist clinical providers regarding completeness of their health record documentation.

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. 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 coordinate and/or perform health record review activities to satisfy external accreditation requirements and medical center performance measures. The MRT HIT notifies clinical providers regarding incomplete health records. They assist clinical providers regarding completeness of their health record documentation, and the correction of health records.

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. 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.

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