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:
- 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.
- 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.
Grade Determinations for Supervisory Medical Records Technician (HIT), GS-08: Supervisory MRTs HIT at the GS-08 grade level provide the full range of supervisory duties, which include responsibility for determining staffing needs, assignment of work, performance evaluation, selection of staff, recommendations of awards and advancements, and disciplinary actions. They perform ongoing audits of staff for all areas of responsibility, and assign work to the staff at an appropriate quality and productivity level. They establish goals, train employees in the accomplishment of tasks or projects, and develop written policies, procedures, and guidelines. They serve as subject matter experts in health record content and documentation requirements. Supervisory MRTs HIT initiate various reports, analyze data, and work closely with clinical services to facilitate timeliness, completion, and accuracy of health record documentation. They monitor, maintain, and create statistical data to include incomplete and delinquent records, as well as quantitative and qualitative analysis findings, to produce reports for medical center management.
Experience. One year of experience equivalent to the next lower grade level, GS-07. 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.
Additionally, the GS-07 knowledge, skills, and abilities are the following:
- 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.
Demonstrated Knowledge, Skills, and Abilities. In addition to the experience above, the candidate must demonstrate the following KSAs:
- Knowledge of operational tasks including record completion, discharge analysis, and abstracting health records, in accordance with facility accreditation, procedures, and regulatory policies.
- Ability to provide expert technical guidance in health record content and documentation requirements.
- Skill in utilizing various software and computer applications to generate and analyze various reports.
- Ability to coordinate and provide staff development and training.
- Ability to coordinate tasks and collaborate with individuals outside the work area and at higher organizational levels.
- Ability to provide the full range of supervisory duties, to include assignment of work, performance evaluation, selection of staff, and recommendation of awards, advancements, and disciplinary actions, when appropriate.
NOTE: Be detailed in your resume as to how you meet these KSAs requirement; otherwise, we will not be able to award you credit for the experience/education/training you claim.
Preferred Experience: 3 to 4 years of experience in Medical Records.
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-08.
Physical Requirements: See VA Directive and Handbook 5019, Employee Occupational Health Service.