Medical Records Technician (ROI)

Clarification from the agency

NOTE: The 2-page Resume requirement does not apply to this position. For more information, refer to Required Documents below. Current federal employees of this agency. Current Excepted Service federal employees. United States Citizens, nationals or those who owe allegiance to the U.S.

The duties in this position are primarily advisory and technical in nature. Incumbent is responsible for evaluating the adequacy of each completed authorization form. Screens each request for information to determine urgency and assures that most urgent requests are completed first using established priority systems. Personally, greets veterans /visitor, assists them in determining the exact nature of the request and whether the information requested can be released.

• Applies public laws, rules, regulations and exclusions governing confidentiality of the medical record, including the Privacy Act, Freedom of Information Act and 38 U.S.C. 7332 governing the release of records containing information regarding the treatment of or referral for drug and/or alcohol abuse, Sickle Cell Anemia and infection with Human Immunodeficiency Virus (HIV).
• The incumbent processes all incoming requests to the facility for Release of Information (ROI) along with information required by the VA Regional Office through the Automated Medical Information Exchange (AMIE).
• Evaluates validity of each request. Determines which information is to be released in compliance with existing laws (Privacy Act of 1974, Freedom of Information Act, and Health Insurance Portability and Accountability Act). Ensures that proper authorization exists before release is made. Processes the request to the requesting agency or individual. Inputs all requests into the DSS ROI computer package for logging and tracking of these requests.
• Receives and directs callers and visitors. Receives and/or gives out forms, and assists visitors and/or callers with the completion of forms or documents. Responds to questions from patients concerning services. Provides advisory and technical assistance to patients, administrative staff and professional staff regarding release of information. Inquiries vary widely and information given requires explanation of office functions, describing specific requirements, providing basic instructions, or a similar degree of detail.
• Searches records or files to compose responses, including electronic searches to retrieve and summarize hard-to-locate data. Locates materials that would verify information given. Reviews paper and computerized health records (i.e., scanned notes, reports, special tests, etc.) to identify material to be photocopied/printed/written to electronic media and released.
• Employee composes responses to routine requests for release of patient information. Selects and compiles information from health records and prepares correspondence, typically using standard form or standard formats for letters. Ensures the information released is limited to what is specifically authorized and to the person or agency designated to receive it.
• Composes detailed explanations in response to correspondence received, arranging information into logical sequence and appropriate format and choosing appropriate words and expressions to convey the desired tone. Determines extent and tone of replies independently.
• Resolves conflicting or inconsistent information found on initial requests. This involves dealing with patients and/or third parties to resolve discrepancies, sorting out errors and reconstructing past transactions, cases or events, or finding alternative sources of information.
• Processes Social Security requests for health information using ROI software. Downloads VistA Imaging documents, Cerner documents, and ROI software documents onto a secure Network Drive. Accesses the secure Social Security Web page and uploads the documents to the Web portal. Transfers the confirmation codes to the ROI software package and closes the request(s) in both the ROI and Social Security packages.
• Completes and processes routine releases of information to other VA and Federal Agencies and when requested, to patients and their families, insurance representatives, physicians, hospitals, and city and state health agencies according to VA directives. Processing must be accomplished within established time standards. Accurately enters all requests into the ROI software with necessary information for each request for health information. Completes necessary transactions for deposit of money collected from subpoenas, legal fees, and processing fees for release of information to individuals and insurance companies.

Work Schedule: Monday-Friday; 8:00am to 4:30pm.
Telework: Ad-Hoc
Virtual: This is not a virtual position.
Functional Statement #: 91876-A, 91877-A, 91878-A, Medical Records Technician (ROI)/CBSR-13003306-26-JD
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.
• Must pass pre-employment physical examination.
• 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 and 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 (ROI) 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 and 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 experience and 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 courses.
  • (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 Armed Forces or the U.S. Maritime Service under close medical and professional supervision. The training program may be substituted on a month-for-month basis for up to six months of experience provided the training program included courses in anatomy and 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).

Grade Determinations: In addition to the Basic Requirements listed above, to qualify for each applicable pay grade, candidates must meet the requirements listed below:

GS-4 Qualifications

• None needed beyond Basic Requirements.

GS-5 Qualifications

• Experience. One year of creditable experience equivalent to the next lower grade level. Experience includes but is not limited to the following: Serving in an entry level role receiving and validating authorization forms and requesting information, and prioritizing requests per policies and regulations; using various computer applications to track and release all authorized ROI requests; processing and releasing health information to authorized first- and third-party requestors; initiating and maintaining the accounting of disclosure for all records disclosed from a Privacy Act system of records; and, ensuring compliance with policies, procedures, laws, and regulations governing privacy and release of information; OR,
• Education. Successful completion of 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 and physiology, legal aspects of health care, and introduction to health records).
• Knowledge, Skills, and Abilities (KSA's). The candidate must demonstrate the following KSA's:
  • Ability to utilize health information technology and various office software products utilized in MRT (ROI) positions (e.g., the electronic health record, release of information systems, etc.).
  • Knowledge of health record documentation guidelines and processes for disclosing protected health information.
  • Ability to manage priorities and coordinate work in order to complete duties within required timeframes, and the ability to follow-up on pending issues.
  • Knowledge of policies, procedures, laws, and regulations governing privacy and release of information.
  • Ability to communicate with individuals from various backgrounds to obtain the desired effect or gaining information by establishing rapport.

GS-6 Qualifications

• Experience. One year of creditable experience equivalent to the next lower grade level. Experience includes but is not limited to the following: Serving in a developmental role receiving and validating authorization forms and requesting information, and prioritizing requests per policies and regulations; using various computer applications to track and release all authorized ROI requests; processing and releasing health information to authorized first- and third-party requestors; initiating and maintaining the accounting of disclosure for all records disclosed from a Privacy Act system of records; and, ensuring compliance with policies, procedures, laws, and regulations governing privacy and release of information.
• Knowledge, Skills, and Abilities (KSA's). The candidate must demonstrate the following KSA's:
  • Knowledge of the laws and regulations related to the authorization and disclosure of health information (e.g., Privacy Act, Freedom of Information Act, Health Insurance Portability and Accountability Act (HIPAA), and 38 U.S.C. § 7332, Confidentiality of Certain Medical Records).
  • Ability to apply health record documentation guidelines and processes to navigate efficiently through the paper and/or electronic health record to locate, assemble, and disclose protected health information
  • Ability to apply policies, procedures, laws, and regulations governing privacy and release of information to process requests for release of information.
  • Ability to research and solve difficult questions related to release of health information in an accurate and timely manner.

References: VA Handbook 5005/123 PART II APPENDIX G58

The full performance level of this vacancy is GS-06. The actual grade at which an applicant may be selected for this vacancy is in the range of GS-04 to GS-06.

Physical Requirements: The work is primary sedentary, although some slight physical effort may be required. There may be some walking, standing, bending, and carrying of light items. Incumbent may be susceptible to eye strain from working long hours on a computer.

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

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

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
• DD-214/ Statement of Service
• Disability Letter (Schedule A)
• Disability Letter (VA)
• License
• Other (1)
• Other (2)
• Other (3)
• Performance Appraisal
• Professional Certification
• Resume
• Separation Notice (RIF)
• SF-15
• SF-50/ Notification of Personnel Action
• Transcript

Next steps