Medical Records Technician (Health Information Technician)

Clarification from the agency

NOTE: The 2-page Resume requirement does not apply to this position. Open to current permanent Department of Veterans Affairs employees.

Duties include but are not limited to the following:

• Incumbent is responsible for performing quantitative and qualitative reviews of health record documentation.
• Incumbent is responsible for ensuring that patient care data entered in VistA and/or Computerized Patient Record System (CPRS) is accurate, timely, and completed.
• Adheres to established documentation requirements as outlined by The Joint Commission regulations, Veterans Health Administration (VHA) guidelines, CMS guidance, as well as medical-legal requirements.
• Identifies health record deficiencies of paper and electronic health records, tracks deficiencies, notes deficiencies in appropriate data base, and ensures that the appropriate individual completes their deficiencies. The incumbent assists physicians with the completion of delinquent/incomplete health records and servers as resource for clinical staff regarding requirements for complete documentation.
• Works independently resolving record deficiency issues/erroneous documents and corrective action required within CPRS and only seeks guidance of management when issues surface that are more challenging or complex.
• Regularly prepares reports noting the status of all incomplete/delinquent records and compliance reports and submits the reports to the committee and staff.
• Performs analytical tasks associated with the resolution of documentation errors, incorrectly entered; wrong patient, appointment, title, consult etc and reassigning. Duties may also include the generation of various statistical report to track errors.
• Develops and compiles written reports trending provider specific, service, and hospital compliance reports regarding admission, subsequent and discharge notes.
• The MRT HIT analyzes, abstracts, maintains, extracts and compiles information from the health record for special studies and audits both internal and external.
• The incumbent utilizes health information technology and various office software products utilized in HIM units (e.g., the electronic health record, electronic health record interchange, Office products, electronic databases, HIMS software systems, Patient Treatment File (PTF), Patient Care Encounter (PCE), voice recognition, transcription and dictation systems etc.)
• The incumbent performs complex health information functions, including web-based programs.
• The incumbent utilizes knowledge of the Joint Commission requirements, CMS guidance and/or health record documentation guidelines to perform functions
• Ability to manage priorities and coordinate work in order to complete duties within required timeframes and ability to follow-up on pending issues.
• Other duties as assigned

Work Schedule: 7:00am to 3:30pm - but tour of duty can be negotiable
Telework: Not Available
Virtual: This is not a virtual position.
Functional Statement #: 000000
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.
• 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:
    • 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 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.
• Physical Requirements. See VA Directive and Handbook 5019, Employee Occupational Health Service.
• English Language Proficiency. MRTs HIT must be proficient in spoken and written English, as required by 38 U.S.C. § 7403(f).

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).

Grade Determinations: All MRT HIT employees assigned to this occupation must have an approved parenthetical title as described below:

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. 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. (GS-5)
• 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.

• 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.

Preferred Experience: health record review, encounter corrections and chart prep experience preferred

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: 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 evaluation or examination.

How you will be evaluated

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

Eligible applications will be reviewed and referred in the following order:
1. Current permanent VA employees of the facility.
2. All other VA Employees

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)
• RECOMMENDED: Responses to Knowledge, Skills and Abilities - Can Be Found Under the Qualification Section of the Job Opportunity Announcement
• Performance Appraisal
• Professional Certification
• 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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