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.
a. Citizenship. Citizen of the United States. (Non-citizens may be appointed when it is not possible to recruit qualified citizens in accordance with chapter 3, section A, paragraph 3g, this part.)
b. Experience and Education.
(1) 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,
(2) 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,
(3) 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.
c. Grandfathering Provision. All persons employed in VHA as a MRT HIT, on the effective date of this qualification standard, 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:
(1) 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.
(2) 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.
(3) 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.
a. Physical Requirements. See VA Directive and Handbook 5019, Employee Occupational Health Service.
b. English Language Proficiency. MRTs HIT must be proficient in spoken and written English, as required by 38 U.S.C. § 7403(f).
5. GRADE REQUIREMENTS. All MRT HIT employees assigned to this occupation must have an approved parenthetical title as described below:
a. MRT (HIT);
b. Lead MRT (HIT); or
c. Supervisory MRT (HIT).
6. GRADE DETERMINATIONS
a. Medical Records Technician (HIT), GS-4 (Entry Level)
(1) Experience or Education. None beyond basic requirements.
(2) 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.
b. Medical Records Technician (HIT), GS-5 (Developmental Level 1)
(1) Experience. One year of experience equivalent to the next lower level.
OR,
(2) 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).
(3) 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. 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 accreditation requirement. They perform health record review activities to satisfy external accreditation requirements and medical center performance measures. They create and monitor reports to ensure that deficiencies are resolved and completed appropriately. They monitor, verify, correct, and/or upload all transcription/medical speech recognition to maintain completeness and accuracy of health records. MRTs HIT notify clinical providers regarding incomplete health records, and assist clinical providers regarding completeness of their health record documentation.
(4) Demonstrated Knowledge, Skills, and Abilities. In addition to the experience above, the candidate must demonstrate all of the following KSAs:
(a) Ability to communicate effectively with internal and external customers.
(b) 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).
(c) Knowledge of health record documentation guidelines and industry standards.
(d) Ability to manage priorities and coordinate work to complete duties within required timeframes.
(e) Ability to apply knowledge of medical terminology and human anatomy to fully understand the content of a health record.
c. Medical Records Technician (HIT), GS-6 Continued in Education Section.
(1) Experience. One year of experience equivalent to the next lower grade level.
Education
(2) 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. 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. They conduct reviews of incomplete records for individuals clearing the facility. They create and monitor reports to ensure that deficiencies are resolved and completed appropriately. They monitor, verify, correct, and/or upload all transcription/medical speech recognition to maintain completeness and accuracy of health records. MRTs HIT serve as the technical experts in health record content and documentation requirements.
(3) Demonstrated Knowledge, Skills, and Abilities. In addition to the experience above, the candidate must demonstrate all of the following KSAs:
(a) Ability to navigate efficiently through the health record to locate needed information.
(b) Ability to analyze health record documentation to ensure compliance with guidelines and industry standards.
(c) Skill in investigating potential health record errors and making corrections, when appropriate.
(d) Skill in interpreting and applying health information guidelines and using 6 judgment to complete assignments.
(e) Ability to follow up on incomplete health record documentation.
d. Medical Records Technician (HIT), GS-7 (Full Performance Level)
(1) Experience. One year of experience equivalent to the next lower grade level.
(2) 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. MRTs HIT prepare complex reports, calculate department statistics, note the status of all incomplete/delinquent records, and submit reports to the appropriate administrative and clinical staff and committees/leadership to ensure deficiencies are resolved and completed appropriately. They serve as the expert resource for clinical staff and assist clinical providers with completion or correction of their health record documentation. They conduct the review of incomplete records for individuals clearing the facility. MRTs HIT coordinate the use of medical speech recognition/transcription and monitor, verify, troubleshoot, correct, and/or upload all transcription/medical speech recognition to maintain completeness and accuracy of health records. They serve as the technical expert in health record content and documentation requirements.
(3) Demonstrated Knowledge, Skills, and Abilities. In addition to the experience above, the candidate must demonstrate all of the following KSAs:
(a) 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.
(b) Ability to take appropriate actions if health record content is not adequate, accurate, timely, and/or reliable.
(c) Ability to communicate both orally and in writing with individuals or groups, to facilitate compliance with established policies and regulations.
(d) Skill in using appropriate software and computer applications to analyze and record documentation trends.
(e) Ability to apply qualitative and/or quantitative methods for assessment and 7 improvement of health records.
(f) 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 GS-07
Physical Requirements:
Physical Demands: Physical aspects associated with work required of this assignment are typical for this occupation, see duty section for essential duties of this position. May require standing, lifting, carrying, sitting, stooping, bending,, pulling, and pushing. May be required to wear personal protective equipment and undergo annual TB screening or testing as conditions of employment.
Work Environment: Work is performed in an office clinic setting with minimal risks that requires normal safety precautions; the area is adequately lighted heated and ventilated. However, the work environment requires someone with the ability to handle several tasks at once and sometimes stressful situations.