Clarification from the agency

The First Area of Consideration will be current, permanent Northport VA Employees. The Second Area of Consideration will be VISN, VA and Other Federal Employees. The Third Area of Consideration will be Public Candidates.

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The incumbent serves as technical expert in health record content and documentation requirements. Incumbent is responsible for performing quantitative and qualitative reviews of health record documentation. Incumbent is 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. Maintains a control system to ensure completion of all inpatient and outpatient records in accordance with VA, The Joint Commission, CMS and other regulatory agencies standards. 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.

A full list of duties can be found in the Functional Statement of this position.

Grade Level Assignments
MRT (HIT), GS-4: Employees at this level serve as entry level MRTs HIT, and receive close supervision from the supervisory MRT HIT or designee. MRTs HIT 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 accrediting bodies. They perform health record review activities to satisfy external accreditation requirements and medical center performance measures. They monitor, verify, correct, and upload all transcription/medical speech recognition to maintain completeness and accuracy of health records.

MRT (HIT), GS-5: Employees at this grade level serve in developmental positions as MRTs HIT. Employees receive guidance from the supervisory MRT HIT, or designee, for more complex health record reviews. MRTs HIT 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 requirement. They perform health record review activities to satisfy external accreditation requirements and medical center performance measures. They create and monitor reports to ensure that deficiencies are resolved and completed appropriately. They monitor, verify, correct, and/or upload all transcription/medical speech recognition to maintain completeness and accuracy of health records. MRTs HIT notify clinical providers regarding incomplete health records, and assist clinical providers regarding completeness of their health record documentation.

MRT (HIT), GS-6: This is a developmental level for MRT HIT. The MRT HIT at this level receives guidance from the supervisory MRT HIT, or designee, for more complex health records. The MRT HIT analyzes, abstracts, maintains, extracts and compiles information from the health record, working under the review of the supervisor. 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 coordinate and/or perform health record review activities to satisfy external accreditation requirements and medical center performance measures. The MRT HIT notifies clinical providers regarding incomplete health records. They assist clinical providers regarding completeness of their health record documentation, and the correction of health records. They conduct reviews of incomplete records for individuals clearing the facility.

MRT (HIT), GS-7: This is considered the journey level for MRTs HIT. 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. records, and submit reports to the appropriate administrative and clinical staff and committees/leadership to ensure deficiencies are resolved and completed appropriately.

Work Schedule: Monday to Friday 8:00am to 4:30pm
Financial Discloser Report: Not required

Conditions of employment

• U.S. Citizenship; non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy.
• Designated and/or random drug testing required
• Selective Service Registration is required for males born after 12/31/1959
• Must be proficient in written and spoken English
• You may be required to serve a probationary period
• Subject to a background/security investigation
• Selected applicants will be required to complete an online onboarding process
• Must pass pre-employment physical examination

Qualifications

BASIC REQUIREMENTS.
a. Citizenship. Be a 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. 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).

Creditable Experience. Experience is only creditable if it is paid or non-paid employment directly related to the position to be filled, or in a related field, such as medical support assistants, clinic/ward clerks, health record file room/scanning technicians, medical coding, or other positions that include knowledge of the content and uses of health records. To be creditable, the candidate's experience must have demonstrated the use of knowledge, skills, and abilities associated with current MRT HIT practice.

Quality of Experience. To be creditable, experience must be documented on the application or resume and verified in an employment reference, or through other independent means.

Part-Time Experience. Part-time experience as a MRT HIT is creditable according to its relationship to the full-time workweek. For example, a MRT HIT would receive one week of full-time credit for each two weeks of half-time work.

Grade Determinations:
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.
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.

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 judgment to complete assignments.
(e) 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:
(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 improvement of health records.
(f) Ability to work independently and utilize problem-solving techniques in the accomplishment of work.

References: VA Handbook 5005/124 December 10, 2019 PART II APPENDIX G59

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: Work is sedentary but also demands standing, walking, bending, twisting, and carrying light items.

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 in sometimes stressful situations.

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, résumé, C.V., and/or supporting documentation will be verified. Please follow all instructions carefully. Errors or omissions may affect consideration for employment.

NOTE: A formal pay-setting process will be used to determine your salary. The salary may be at any point in the range listed for this vacancy.

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.