Medical Records Technician - Health Information Technician

Clarification from the agency

This position is ONLY open to current, permanent VA Sheridan Health Care System Employees. NOTE: The 2-page Resume requirement does not apply to this position.

• Serves as technical expert in health record content and documentation requirements. Responsible for performing quantitative and qualitative reviews of health record documentation for ongoing regulatory reviews and deficiency analysis. Responsible for ensuring that all patient care data entered in the electronic health record (EHR) is accurate, timely, and complete. Adheres to established documentation requirements as outlined by The Joint Commission (TJC) regulations, Veterans Health Administration (VHA) guidelines, as well as medico-legal requirements.
• Reviews health records for adherence with the Centers for Medicare and Medicaid Services (CMS) guidelines related to student, resident supervision and attending physician presence and documentation. Compiles reports to ensure provider specific and service compliance. Maintains a control system to ensure completion of all inpatient and outpatient health records in accordance with VHA, TJC, CMS and other regulatory agencies' standards.
• Reviews health records to ensure that all health records contain sufficient information to meet medico-legal requirements, to ensure continuity of patient care, and to support education and research needs. Notifies clinicians of missing, incomplete, or inaccurate
  information in their signature blocks (e.g., missing or inaccurate credentials). Assist clinicians with completion of delinquent/incomplete health records.
• Assesses the health record for completeness, identifies health record deficiencies, tracks deficiencies, and ensures that the appropriate individuals complete their deficiencies. Notates documentation deficiencies in the appropriate deficiency monitoring application. Tracks unsigned/un-cosigned notes (e.g., progress notes, operative reports, discharge summaries, etc.) and encounters without associated
  progress notes and communicates these deficiencies to clinical staff for completion. Notification can be in person, through secure email, via telephone, or through other acceptable means.
• Responsible for expediting the completion of the health record when the patient is transferred for care at another medical center, for legal requests, regulatory agencies review, and reimbursement purposes.
• 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.
• If site utilizes Dragon and assigns medical speech recognition (MSR) duties to the HIM Department, coordinates and monitors the use of medical speech recognition and troubleshoots with clinicians, as needed, to maintain completeness and accuracy of health records. Provides Dragon Local Administrator duties that typically include: creating new user accounts in the Nuance Management Center, act as a local POC for Dragon questions, referrals and guidance, troubleshoot technical problems with local IT as needed, assist clinical end users with log on and provide user guides, create and maintain a facility Dragon User Outlook mail group to facilitate MSR communications, submit tickets to Nuance Government Support, as needed, listen in and participate on the VHA MSR Administration calls, provide training tools and resources, facilitate purchase and distribution of headsets/microphones as needed, and provide Dragon
  usage reports to leadership.
• Works with interdisciplinary staff to solve problems regarding proper health record documentation and completion. Consults with the appropriate clinician(s) for clarification when conflicting or ambiguous information appears in the health record documentation.
• Prepares complex reports on a routine basis, noting the status of all incomplete/delinquent health records, and submits the reports to the appropriate administrative and clinical staff. Develops and compiles written reports trending provider specific, service, and hospital compliance reports regarding admission, subsequent and discharge progress notes. Obtains statistical information, applies statistical formulas, and completes statistical reports for medical center management.

Work Schedule: Monday - Friday, 7:30am - 4:00pm
Telework: Available on an ad-hoc basis.
Virtual: This is not a virtual position.
Functional Statement #: 61593-0 / 61594-0 / 61595-0 / 61596-0
Relocation/Recruitment Incentives: Not authorized.
Permanent Change of Station (PCS): 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 identification 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.

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 (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.

Grandfathering Provision. All persons employed in VHA as a MRT HIT, on the effective date of this qualification standard (12/10/2019), 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.

Grade Determinations:

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 (GS-4).

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 (KSAs). 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.

Medical Records Technician (HIT), GS-6
Experience. One year of experience equivalent to the next lower grade level (GS-5).

Demonstrated Knowledge, Skills, and Abilities (KSAs). 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 judgment to complete assignments.
• (e) 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 (GS-6).

Demonstrated Knowledge, Skills, and Abilities (KSAs). 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 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-7. The actual grade at which an applicant may be selected for this vacancy is in the range of GS-4 to GS-7.

Physical Requirements: See VA Directive and Handbook 5019, Employee Occupational Health Service.

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:

• Long-form resume/Curriculum vitae (CV)
• SF-50/ Notification of Personnel Action

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
• Long-form resume/Curriculum vitae (CV)
• Other (1)
• Professional Certification
• SF-50/ Notification of Personnel Action
• Transcript

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

Next steps