Medical Records Technician (Health Information Technician)

Summary

This position is located in the Health Information Management (HIM) section at the Southeast Louisiana Veterans Healthcare System (SLVHCS). MRTs HIT perform incomplete health record analysis. They review, analyze, abstract, maintain, extract, and compile information from the health record. MRTs HIT check for accuracy, completeness, and timeliness of the health record and monitor and report for regulatory compliance.

Duties

The duties of the Medical Records Technician (Health Information Technician) include, but are not limited to: The incumbent is responsible for abstraction of clinical information for ongoing regulatory reviews and deficiency analysis. Contacts physicians and other ancillary service personnel regarding dictation and/or signatures. Assists clinical staff by providing information as to required documentation. Communicates very closely with the clinical staff to answer questions and resolve problems to ensure quality documentation in the health records. Assists with capture and reporting of health record documentation deficiencies and notates documentation deficiencies in the appropriate deficiency monitoring application. Monitors delinquent dictation list for follow-up purposes on necessary documents (i.e., operation reports, discharge summaries, etc.) that are needed for completion of health records. Notifies appropriate physician and other personnel of the status of dictation. Monitors house staff rotation schedule and contacts resident house staff to ensure completion of health records prior to departure from the Medical Center. Participates in approved quality improvement focused reviews. Utilizes basic knowledge of medical terminology, anatomy and physiology, and coding to research and collect information for various medical studies and research projects. Coordinates review activities with the Quality Improvement Program to satisfy external accreditation requirements and to satisfy current Medical Center performance measures. Collects data from data validation activities and audits that support continuity of patient care, budget/resource allocation, performance measurement, quality management, research, VA comparative analysis and benchmarking. 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. Assists with capture and reporting of health record documentation deficiencies and notates documentation deficiencies in the appropriate deficiency monitoring application. Monitors delinquent dictation list for follow-up purposes on necessary documents (i.e., operation reports, discharge summaries, etc.) that are needed for completion of health records. Notifies appropriate physician and other personnel of the status of dictation. Monitors house staff rotation schedule and contacts resident house staff to ensure completion of health records prior to departure from the Medical Center. Assists physicians with the completion of delinquent/incomplete health records and servers as the expert resource for clinical staff regarding requirements for complete 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. Reviews health records to ensure that all 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). Assists clinicians with completion of delinquent/incomplete health records. Works independently to resolve incomplete health record deficiency and erroneous documentation issues and only seeks guidance of immediate supervisor when issues surface where no precedent or procedure has been developed. Collects, interprets, and trends data from data validation activities and audits that support continuity of patient care, budget/resource allocation, performance measurement, quality management, research, VA comparative analysis and benchmarking. Participates in routine and focused reviews for the purpose of identifying problems and potential problems in health record documentation as part of the health record review process. Identifies and abstracts information from health records for special studies and audits both internal and external. Work Schedule: Monday - Friday, 7:30 am - 04:00 pm, (Subject to change based on the needs of the facility.) Telework: Available Virtual: This is not a virtual position. Functional Statement #: 01300F, 01301F, 01437F, 01438F Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized Requirements

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 evaluation. 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

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. b. Medical Records Technician (HIT), GS-5 (Developmental Level 1) Experience. One year of experience equivalent to the next lower level. 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: (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 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: (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). 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: (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. Continued in the Education section:

Education

Preferred Experience: Tech-savvy; quickly learns new software, EHR, and deficiency-tracking/health information systems. Intermediate to expert Microsoft Office (Word, Excel, PowerPoint, Outlook), including generating statistical/compliance reports and analyzing data. Experience conducting quantitative and qualitative health record reviews for regulatory compliance (TJC, CMS, VHA). Familiarity with medical speech recognition (e.g., Dragon/Nuance) and transcription workflows, including troubleshooting and local administration. Skill in tracking, trending, and reporting health record deficiencies and communicating them to clinical staff. Experience delivering presentations and developing training for clinical and non-clinical staff on documentation requirements. Able to manage multiple concurrent projects and competing deadlines while maintaining accuracy. LEAN (or Lean Six Sigma) training or certification. 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 in the range of GS-04 to 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. Note: Only education or degrees recognized by the U.S. Department of Education from accredited colleges, universities, schools, or institutions may be used to qualify for Federal employment. You can verify your education here: http://ope.ed.gov/accreditation/. If you are using foreign education to meet qualification requirements, you must send a Certificate of Foreign Equivalency with your transcript in order to receive credit for that education. For further information, visit: https://sites.ed.gov/international/recognition-of-foreign-qualifications/. How You Will Be Evaluated

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. Other Information

During the application process you may have an option to opt-in to make your resume available to hiring managers in the agency who have similar positions. Opting in does not impact your application for this announcement, nor does it guarantee further consideration for additional positions. This job opportunity announcement may be used to fill additional vacancies. This position is in the Excepted Service and does not confer competitive status. VA encourages persons with disabilities to apply. The health-related positions in VA are covered by Title 38, and are not covered by the Schedule A excepted appointment authority. If you are unable to apply online or need an alternate method to submit documents, please reach out to the Agency Contact listed in this Job Opportunity Announcement. Under the Fair Chance to Compete Act, the Department of Veterans Affairs prohibits requesting an applicant's criminal history prior to accepting a tentative job offer. For more information about the Act and the complaint process, visit Human Resources and Administration/Operations, Security, and Preparedness (HRA/OSP) at The Fair Chance Act.