Medical Records Technician (HIT)

Summary This position is located in the Health Information Management (HIM) section of the Patient Business Service at the Chalmers P. Wylie

Va Acc.

Medical Record Technicians (MRT) 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. Duties Duties include, but are not limited, to the following: Performs quarterly quantitative audits of medical records to evaluate problems and potential problems. Ensures compliance with The Joint Commission standards, VA regulations and directives and standards of practice pertaining to documentation (timeliness, accuracy, completeness). Prepares narrative and graphic information (as requested) of data analyzed for the Chief HIMS/Supervisory Medical Records Administrative Specialist. Determines the cause of inadequacies/errors and suggests corrective measures- reports include indicators for medical record timeliness, consults, registry exams. Serves as the point of contact for Dragon Medical Software. Provides technical assistance and advice to administrative, medical and professional staff and support staff regarding documentation guidelines, consults, Special Environmental Health Registry exams, Dragon Medical Software, and other HIMS functions as needed. Acts as facility decedent affairs to promptly respond to requests from coroner offices regarding the need for completion of death certificates and medical record information for autopsies. Researches ways to retrieve a death certificate if not provided by the funeral home or family of the deceased Veteran. Reviews, analyzes, abstracts, compiles, maintains, and/or extracts health data to perform duties within the scope of duties such as organizing medical records, checking for completeness, accuracy and compliance, and/or scanning, privacy, research, education, revenue, or similar functions. Work Schedule: Monday thru Friday, 8:00am

• 4:30pm Telework: Ad-hoc as determined by the agency policy. Virtual: This is not a virtual position. Functional Statement #: 917150/917160/917170/915650 Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized Qualifications Applicants pending the completion of educational or certification/licensure requirements may be referred and tentatively selected but may not be hired until all requirements are met. 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. 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. May qualify based on being covered by the Grandfathering Provision as described in the VA Qualification Standard for this occupation (only applicable to current VHA employees who are in this occupation and meet the criteria). English Language Proficiency. MRTs HIT must be proficient in spoken and written English, as required by 38 U.S.C. § 7403(f). Grade Determinations And Assignments. Medical Records Technician (HIT), GS-4 (Entry Level) Experience or Education. None beyond basic requirements. 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). 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. 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 judgement 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. 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 appro