Clarification from the agency

NOTE: The 2-page Resume requirement does not apply to this position. For more information, refer to Required Documents below. This is an INTERNAL ANNOUNCEMENT and is limited to current permanent employees of the VA Central Iowa Health Care System to include CBOCS.

The position requires the incumbent to physically report for work to the Des Moines, IA VAMC.

Major duties include, but are not limited to:

• Performs quantitative and qualitative reviews of health record documentation for ongoing regulatory compliance and deficiency analysis. Ensures all patient care data entered in the electronic health record (EHR) is accurate, timely, and complete in accordance with The Joint Commission (TJC), Veterans Health Administration (VHA), Centers for Medicare and Medicaid Services (CMS), and medico-legal requirements.
• Reviews health records for adherence with CMS guidelines related to student and resident supervision, attending physician presence, and documentation. Compiles provider-specific and service compliance reports. Maintains a control system to ensure completion of all inpatient and outpatient records per VHA, TJC, CMS, and other regulatory standards.
• Assesses records for completeness; identifies, tracks, and notates deficiencies in the appropriate monitoring application. Tracks unsigned/un-cosigned notes (e.g., progress notes, operative reports, discharge summaries) and encounters without associated progress notes, communicating deficiencies to clinical staff via in-person, secure email, telephone, or other acceptable means. Notifies clinicians of missing, incomplete, or inaccurate information in signature blocks and assists with completion of delinquent records.
• Consults with clinicians to clarify conflicting or ambiguous documentation. Performs administrative corrections to the health record, including correcting note titles, designating correct signers/cosigners, and ensuring notes are attached to the correct episode of care. Utilizes EHR functionality to analyze, manage, and monitor documentation deficiencies and communicates with staff to resolve them per facility policies and performance goals.
• Expedites health record completion when patients are transferred to another medical center, and for legal requests, regulatory reviews, and reimbursement purposes. Works independently to resolve deficiency issues and erroneous documents within the EHR, seeking supervisor guidance only when no precedent or procedure exists.
• Performs lead functions over MRT (HIT) positions. Distributes and balances workload among team members; monitors work status and adjusts priorities as needed. Assures timely accomplishment of assigned work and that each team member has an integral role in delivering the final product or service.
• Trains team members on tasks, procedures, policies, and directives; provides expert advice and answers procedural questions. Makes written instructions and reference materials available. Coaches team members in identifying viable solutions and integrates the organization's vision into team goals, strategies, and work plans. Ensures participation in both short- and long-term planning.
• Builds consensus among team members; serves as negotiator and coach for coordination of team initiatives. Resolves simple informal employee complaints; refers more serious matters to the supervisor. Maintains records of work accomplishments and checks work in progress to verify supervisor instructions are met. Provides recommendations to the supervisor regarding promotions, reassignments, recognition of performance, and personnel needs.

Work Schedule: Monday thru Friday, 7:30 am to 4:00 pm
Telework: Ad-hoc
Virtual: This is not a virtual position.
Functional Statement #: 000000
Relocation/Recruitment Incentives: Not Authorized

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.
• Subject to background/security investigation.
• Selected applicants will be required to complete an online onboarding process. Acceptable form(s) of identification will be required to complete pre-employment requirements (https://www.uscis.gov/i-9-central/form-i-9-acceptable-documents). Effective May 7, 2025, driver's licenses or state-issued dentification cards that are not REAL ID compliant cannot be utilized as an acceptable form of identification for employment.
• Participation in the seasonal influenza vaccination program is a requirement for all Department of Veterans Affairs Health Care Personnel (HCP).
• Complete all application requirements detailed in the "Required Documents" section of this announcement.

As a condition of employment for accepting this position, you will be required to serve a 1 or 2-year trial period during which we will evaluate your fitness and whether your continued employment advances the public interest. In determining if your employment advances the public interest, we may consider:

• your performance and conduct;
• the needs and interests of the agency;
• whether your continued employment would advance organizational goals of the agency or the Government; and
• whether your continued employment would advance the efficiency of the Federal service.

Upon completion of your trial period, your employment will be terminated unless you receive certification, in writing, that your continued employment advances the public interest.

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.

Citizenship. [Candidates must be a citizen] of the United States. Non-citizens may be appointed when it is not possible to recruit qualified candidates in accordance with 38 U.S.C. § 7407(a).

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.

(a) 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.

(b) 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).

Physical Requirements. You will be asked to participate in a pre-employment examination or evaluation as part of the pre-employment process for this position. Questions about physical demands or environmental factors may be addressed at the time of the evaluation or examination.

English Language Proficiency. MRTs must be proficient in spoken and written English. See 38 U.S.C. § 7403(f).

Grade Determinations: Lead Medical Records Technician (HIT) GS-8

Experience. One year of experience equivalent to the next lower grade level.

AND

Demonstrated Knowledge, Skills, and Abilities. In addition to the experience above, the candidate must demonstrate all of the following KSAs:
i. Comprehensive knowledge of health record technology methods, procedures, and techniques.
ii. Ability to work with a team to provide technical guidance, and to plan, organize, and coordinate activities to effectively complete job assignments (i.e., distributing workload, monitoring the status and progress of work, monitoring accuracy of work, and ensuring required timelines are met.)
iii. Skill in communicating effectively, both orally and in writing, to meet program objectives.
iv. Ability to prepare reports in a variety of formats and present data to individuals at various organizational levels.
v. Ability to coordinate and provide staff development and training

Assignment. For all assignments above the full performance level, the higher-level duties must consist of significant scope, complexity (difficulty), range of variety, and be performed by the incumbent at least 25% of the time. Lead MRTs HIT perform quantitative and qualitative reviews of health record documentation, initiate various reports, and analyze data. They coordinate, assign, and monitor the workflow. They ensure that team assignments are carried out by distributing and balancing workload, monitoring the status and progress of work, and adjusting workload in accordance with established priorities, instructing and answering employee questions, checking employee work, and amending or rejecting work that does not meet work standards. They resolve informal complaints of employees and make recommendations to the supervisor, as requested, concerning promotions, reassignments, recognition of performance, and personnel needs. Lead MRTs HIT train and provide expert advice on specific tasks, procedures, and policies. They serve as technical expert in health record content and documentation requirements, and as an expert resource for clinical staff regarding requirements for complete documentation. They create statistical reports for medical center management. Lead MRTs HIT are responsible for assisting staff with completing the health record for patient transfers, legal cases, or other urgent requests. They identify and abstract information from health records for internal and external audits and special studies.


Preferred Experience:

• Extensive experience performing incomplete health record analysis, including the review, interpretation, and validation of clinical documentation for accuracy, completeness, and timeliness in accordance with VHA policies, Joint Commission standards, and regulatory requirements.
• Demonstrated ability to coordinate, assign, and monitor the daily workflow of a health information management team, ensuring accuracy and efficiency while maintaining compliance with established priorities and performance metrics.
• Proven track record in mentoring, training, and providing technical guidance to staff in health information management functions, including documentation standards, workload distribution, and quality improvement initiatives.
• Strong knowledge of qualitative and quantitative health record review processes, data abstraction, and reporting functions. Skilled in compiling and analyzing health record data to identify trends, deficiencies, and opportunities for process improvement.
• Experience utilizing health information systems such as VistA, CPRS, and other electronic medical record applications to extract, compile, and report key performance indicators.
• Ability to collaborate effectively with clinical and administrative staff to ensure complete and accurate documentation to support patient care, legal, coding, and billing purposes.
• Competence in generating statistical reports, monitoring documentation compliance, and assisting with internal and external audits, legal record requests, patient transfers, and other urgent data needs.
• Exceptional organizational, analytical, and communication skills supporting a leadership role in a complex healthcare environment.

Reference: For more information on this qualification standard, please visit https://www.va.gov/ohrm/QualificationStandards/.Medical Records Administrator Qualification Standard

How you will be evaluated

You will be evaluated for this job based on how well you meet the qualifications above.

IN DESCRIBING YOUR EXPERIENCE, PLEASE BE CLEAR AND SPECIFIC. WE MAY NOT MAKE ASSUMPTIONS REGARDING YOUR EXPERIENCE. Your application, resume, C.V., and/or supporting documentation will be verified. Please follow all instructions carefully. Errors or omissions may affect consideration for employment.

Experience refers to paid and unpaid experience, including volunteer work done through National Service programs (e.g., Peace Corps, AmeriCorps) and other organizations (e.g., professional; philanthropic; religions; spiritual; community; student; social). Volunteer work helps build critical competencies, knowledge, and skills and can provide valuable training and experience that translates directly to paid employment. You will receive credit for all qualifying experience, including volunteer experience.

The Department of Veterans Affairs performs pre-employment reference checks as an assessment method used in the hiring process to verify information provided by a candidate (e.g., on resume or during interview or hiring process); gain additional knowledge regarding a candidate's abilities; and assist a hiring manager with making a final selection for a position.

It is the policy of the VA to not deny employment to those that have faced financial hardships or periods of unemployment.

Veterans and Transitioning Service Members: Please visit the VA for Vets site for career-search tools for Veterans seeking employment at VA, career development services for our existing Veterans, and coaching and reintegration support for military service members.

To apply for this position, you must provide a complete Application Package which includes:

• Resume
• SF-50/ Notification of Personnel Action

Special Note for Applications: To complete your application, please use the following link https://vacareers.va.gov/wp-content/uploads/sites/5/Resume.docx to download the standard Clinical Resume Document. This one-page document does not need to be modified and must be uploaded into the two-page restricted 'Resume' document upload field.

Your full resume/CV may be uploaded without page limitation into the 'Other' document upload field.

The following documents are accepted, and may be required if applicable to your eligibility and/or qualifications for this position. Please ensure you have included all documents required for your application, such as a copy of your transcript (if using education to qualify), SF-50's (current/former Federal employees), etc.

• Cover Letter
• Responses to the Knowledge, Skills, and Abilities (KSAs) on a separate document - KSAs are found under qualification/grade requirements in the announcement.
• Your full resume/CV may be uploaded without page limitation.
• Professional Certification
• Resume
• SF-50/ Notification of Personnel Action
• Transcript

Veterans' preference does not apply for internal or other current permanent Federal agency employees.

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