Vacancy Identification Number (VIN): 11103869.Learn more about this agency
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This is NOT a Remote or Virtual telework position.
This job opportunity announcement (JOA) will be used to fill one (1) full-time and permanent Medical Records Technician (Health Information Technician) (MRT HIT) vacancies at the Mt. Home VA Medical Center in Johnson City, TN with with Business Office Service.
This position is located in the Health Information Management (HIM) section at the Mountain Home VA Healthcare System. Health Information Technicians (HITs) review, analyze, abstract, compile, maintain, and extract information from the health record . They also check for completeness and accuracy of the health record, and monitor and report for regulatory compliance.
HITs review, analyze, abstract, compile, maintain, and extract information from the health record. Check for completeness and accuracy of the health record , and monitor and report for regulatory compliance.
The Medical Record Technician (HID is a staff position located under the HIMs section of Business Office Service at the James H. Quillen Veterans Affairs Medical Center. James H. Quillen VA Medical Center is a 111 bed general medical, surgical, and psychiatric teaching Medical Center with more than 31 medical specialties and subspecialties. In addition, there is a 348 bed Domiciliary and a 120 bed Nursing Home Care unit.
Duties include, but are not limited to:
- Serves as technical expert in health record content and documentation requirements.
- Responsible for performing quantitative and qualitative reviews of health record documentation.
- Responsible for ensuring that all 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, as well as medical-legal requirements.
- Reviews records for adherence with CMS guidelines related to student, resident supervision and attending physician presence and documentation.
- Compiles reports to insure provider specific and service compliance.
- Reviews health records to ensure that all records contain sufficient information to meet medical/legal requirements, to ensure continuity of patient care, and to support education and research needs.
- Assists clinicians with completion of delinquent/incomplete health records.
- Performs the quantitative and qualitative analysis on both computer and paper based health records.
- Consults with the appropriate clinician(s) for clarification when conflicting or ambiguous information appears in the health record documentation.
- Identifies health record deficiencies, tracks deficiencies and ensures that the appropriate individual completes their deficiencies.
- Assists physicians with the completion of delinquent/incomplete health records and serves as the expert resource for clinical staff regarding requirements for complete documentation.
- 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.
- Assesses the paper health record and electronic Computerized Patient Record System (CPRS) for completeness and notes deficiencies.
- Tracks electronic signatures and documents deficiencies and communicates these deficiencies to clinical staff for correction.
- Works independently resolving health record deficiency issues/erroneous documents and corrective action required within CPRS and only seeks guidance of immediate supervisor and/or Clinical Application Coordinator when issues surface when no precedent or procedure has been developed.
- Prepares complex weekly and monthly reports noting the status of all incomplete/delinquent records and compliance reports and submits the reports to the appropriate administrative and clinical staff.
- Preforms analytical tasks associated with the resolution of "filing" errors on reports uploaded by a transcription vendor.
- Makes appropriate recommendations for changes or solutions and implements appropriate recommendations for corrective action when authorized so continued filing errors do not occur.
- Develops and compiles written reports trending provider specific, service, and hospital compliance reports regarding admission subsequent and discharge notes.
- Other duties as assigned.
Work Schedule: Monday - Friday, 07:45 a.m. to 4:30 p.m.
Telework: NOT Available
Position Description/PD#: Medical Records Technician (Health Information Technician) MRT (HIT)/Functional Statement 000000
Relocation/Recruitment Incentives: Not Authorized
Financial Disclosure Report: Not required
This job originated on www.usajobs.gov. For the full announcement and to apply, visit www.usajobs.gov/GetJob/ViewDetails/600066600. Only resumes submitted according to the instructions on the job announcement listed at www.usajobs.gov will be considered.