Perform incomplete health record analysis by reviewing, analyzing, abstracting, maintaining, extracting, and compiling information from the health record. Check for accuracy, completeness, and timeliness of the health record and monitor and report for regulatory compliance.
Summary
Perform incomplete health record analysis by reviewing, analyzing, abstracting, maintaining, extracting, and compiling information from the health record. Check for accuracy, completeness, and timeliness of the health record and monitor and report for regulatory compliance.
Preference veterans will receive first consideration, will be referred in the following order: 1) CPS/CP; 2) XP; 3) TP; 4) SSP; 5) All other qualified US citizens. *See "How You Will Be Evaluated" for additional information.
Review health records to ensure all records contain enough information to meet medical/legal requirements, to ensure continuity of patient care, and to support education and research needs.
Analysis of PTF procedures track and monitor PTF errors and transmit corrected data timely. Set work priorities and meet deadlines for closing PTF records, preparing delinquent records, preparing excel spreadsheet and completing incomplete reports.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.
Identifies PTF deficiencies, tracks deficiencies and ensures that the appropriate individual completes their deficiencies. The incumbent sends physicians with the incomplete/delinquent health records and serves as the expert resource for clinical staff regarding requirements for complete documentation.
Assesses the paper health record and electronic Computerized Patient Record System (CPRS) for completeness and notes deficiencies in the (IRT, Nuance, VISTA, VISTA Imaging).
Tracks and documents deficiencies and communicates these deficiencies to clinical staff for correction. Notification can be in person, internal e-mail, telephone, or through other normal routing system. Works independently resolving record deficiency issues/erroneous documents and corrective action required within CPRS and seeks guidance of immediate supervisor and/or Clinical Application Coordinator when issues surface when no precedent or procedure has been developed.Review and validate the Edit Analysis Lists (EALs) and the Dispositions in the PTF Master File (419). The EALs are sent in a VistA Mailman message in response to PTF or census transmissions that have data errors. The 419 and census reports are based in Austin at the AITC and require special access.
Prepares complex weekly and monthly reports noting the status of all incomplete/delinquent records and compliance reports and submits the reports to the Chief of HIMS, BP Leadership and clinical staff.
Performs analytical tasks associated with the resolution of "filing" errors on reports uploaded onto spreadsheet. This includes correctly identifying the coder on the report and providing this information to be corrected. Duties may also include the generation of various statistical report to track these errors. Makes appropriate recommendations for changes or solutions and facilitate corrective action when applicable.
Identifies reviews, verifies, and corrects all statistical data concerning MR post reports.
Develops and compiles written reports trending provider specific, service, and hospital compliance reports regarding admission subsequent and discharge notes.
Identifies and abstracts information from health records for special studies and audits both internal and external.
Work Schedule: Monday-Friday 8:00 am - 4:30 pm Telework: Available. Virtual: This is not a virtual position. Remote: This is not a remote position. Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized Financial Disclosure Report: Not 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 background/security investigation.
Selected applicants will be required to complete an online onboarding process.
Participation in the seasonal influenza vaccination program is a requirement for all Department of Veterans Affairs Health Care Personnel (HCP).
Participation in the Coronavirus Disease 2019 (COVID-19) vaccination program is a requirement for all Veterans Health Administration Health Care Personnel (HCP) - See "Additional Information" below for details.
Qualifications
Basic Requirements:
United States Citizenship: Non-citizens may only be appointed when it is not possible to recruit qualified citizens IAW VA Policy.
Experience: 1 year of creditable experience that indicates knowledge of medical terminology, anatomy, physiology, and a general understanding of health records. 6 months of the required 1 year of creditable experience must have provided the knowledge, skills, and abilities (KSAs) needed to perform HRT HIT work; OR,
Education: Associate's degree from an accredited college/university recognized by the U.S. Department of Education, w/ a major field of study in health information technology/management, or related degree with a min. 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 that qualify for meeting the basic requirements. The following educational/training substitutions are appropriate for combining education and creditable experience:
6 months of creditable experience that indicates knowledge of medical terminology, privacy and release of information, the health record, and 1 year above high school, w/ a min. of 6 semester hours of health information technology/health information management.
6 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 my 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 6 months of experience, provided the training program included courses in anatomy, 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: GS-04 Experience/Education: None beyond the basic requirement.
GS-05 Experience/Education: Experience. 1 year of creditable experience equivalent to the next lower grade level which may include but is not limited to: analyze health records for accuracy, completeness, timeliness, consistency, and compliance w/ HIM industry standards, policies, procedures, laws, regulations, and accrediting bodies. Perform health record review activities to satisfy external accreditation requirements and medical center performance measures. Monitor, verify, correct, and upload all transcription/medical speech recognition to maintain completeness and accuracy of health records. OR, Education. Successful completion of a bachelor's degree from an accredited college or university recognized by the U.S. Department of Education, w/ a major field of study in health information management, or a related degree w/ a minimum of 24 semester hours in health information management or technology (e.g. courses in medical terminology, anatomy & physiology, legal aspects of health care, and introduction to health records). Demonstrated KSAs. In addition to the education/experience above, must demonstrate all of the following:
Ability to communicate effectively w/ internal/external customers.
Ability to utilize health information technology and various office software products used in health information management positions.
Knowledge of health record documentation guidelines and industry standards.
Ability to manage priorities and coordinate work to complete duties w/in required time frames.
Ability to knowledge of medical terminology and human anatomy to fully understand the content of a health record.
GS-06 Experience. 1 year of creditable experience equivalent to the next lower grade level. This experience may include but is not limited to: Analyze health records for accuracy, completeness, timeliness, consistency, and compliance w/ HIM industry standards, policies, procedures, laws, regulations, and accreditation requirement. Perform health record review activities to satisfy external accreditation requirements and medical center performance measures. Create and monitor reports to ensure that deficiencies are resolved and completed appropriately. Monitory, verify, correct, and/or upload all transcription/medical speech recognition to maintain completeness and accuracy of health records. Notify clinical providers regarding incomplete health records, and assist clinical providers regarding completeness of their health record documentation. Demonstrated KSAs. In addition to the education/experience above, must demonstrate all of the following:
Ability to navigate efficiently through the health record to locate needed information.
Ability to analyze health record documentation to ensure compliance with guidelines and industry standards.
Skill in investigating potential health record errors and making corrections, when appropriate.
Skill in interpreting and applying health information guidelines and using judgment to complete assignments.
Ability to follow up on incomplete health record documentation.
GS-07 Experience. 1 year of creditable experience equivalent to the next lower grade level which may include but is not limited to: Analyze, abstract, maintain, extract and compile information from the health record, working under the review of the supervisor. Analyze health records for accuracy, completeness, timeliness, consistency, and compliance w/ HIM industry standards, policies, procedures, laws, regulations, and accreditation requirements. Coordinate and/or perform health record review activities to satisfy external accreditation requirements and medical center performance measures. Notifies clinical providers regarding incomplete health records. Assist clinical providers regarding completeness of their health record documentation, and the correction of health records. Conduct reviews of incomplete records for individuals clearing the facility. Create and monitor reports to ensure that deficiencies are resolved and completed. Monitor, verify, correct, and/or upload all transcription/medical speech recognition to maintain completeness and accuracy of health records. Demonstrated KSA's. In addition to the education/experience above, must demonstrate all of 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 w/ 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.
References: VA Handbook 5005/124, Part II, Appendix G59
Physical Requirements: Work requires walking, bending, sitting and occasional standing. The work requires repeat of same movements, sitting for long periods of time. Verbal, auditory and written capabilities to effectively communicate in a articulate manner. The work requires reaching overhead, above shoulders to retrieve files and/or supplies.
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-05 to GS-07.
Education
IMPORTANT: A transcript must be submitted with your application if you are basing all or part of your qualifications on education.
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: http://www.ed.gov/about/offices/list/ous/international/usnei/us/edlite-visitus-forrecog.html.
Additional information
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.
Pursuant to VHA Directive 1193.01, VHA health care personnel (HCP) are required to be fully vaccinated against COVID-19 subject to such accommodations as required by law (i.e., medical, religious or pregnancy). VHA HCPs do not include remote workers who only infrequently enter VHA locations. If selected, you will be required to be fully vaccinated against COVID-19 and submit documentation of proof of vaccination before your start date. The agency will provide additional information regarding what information or documentation will be needed and how you can request a legally required accommodation from this requirement using the reasonable accommodation process.
If you are unable to apply online or need to fax a document you do not have in electronic form, view the following link for information regarding an Alternate Application.
A career with the U.S. government provides employees with a comprehensive benefits package. As a federal employee, you and your family will have access to a range of benefits that are designed to make your federal career very rewarding. Opens in a new windowLearn more about federal benefits.
Eligibility for benefits depends on the type of position you hold and whether your position is full-time, part-time or intermittent. Contact the hiring agency for more information on the specific benefits offered.
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 resume must include the following information for each job listed:
Job Title & Duties (be as detailed as possible)
Month & Year of Start/End dates (i.e. June 2007 to April 2008)
Indicate Full-time or Part-time status (include hours worked per week)
References, to include contact information
If your resume includes a photograph or other inappropriate material or content (Personally Identifiable Information (PII)), it will not be used, and you may not be considered 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.
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.
Preference veterans will receive first consideration and will be referred in the following order:
CPS/CP: A veteran who served at any time and who has a compensable service-connected disability rating of at least 10 percent.
XP: A veteran who served at any time and has a present service-connected disability or is receiving compensation, disability retirement benefits, or pension from the military or the Department of Veterans Affairs but does not qualify as a CP or CPS; or is a purple heart recipient.
TP: 5-point preference based on eligible active duty service.
SSP (Sole Survivorship Preference): Discharged from active duty from the armed forces, after August 29, 2008, by reason of a "sole survivorship discharge."
A career with the U.S. government provides employees with a comprehensive benefits package. As a federal employee, you and your family will have access to a range of benefits that are designed to make your federal career very rewarding. Opens in a new windowLearn more about federal benefits.
Eligibility for benefits depends on the type of position you hold and whether your position is full-time, part-time or intermittent. Contact the hiring agency for more information on the specific benefits offered.
The following documents are accepted, and may be required if applicable to your eligibility and/or qualifications for this position. Please use this checklist to 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.
DD-214/ Statement of Service
Disability Letter (Schedule A)
Disability Letter (VA)
License
Other (1)
Other (2)
Other (3)
Professional Certification
Resume
Separation Notice (RIF)
SF-15
SF-50/ Notification of Personnel Action
Transcript
Veterans' Preference: When applying for Federal Jobs, eligible Veterans should claim preference for 5pt (TP), 10pt (CP/CPS/XP), or for Sole Survivor Preference (SSP) in the questionnaire. You must provide a legible copy of your DD214(s) which shows dates and character of service (honorable, general, etc.). If you are currently serving on active duty and expect to be released or discharged within 120 days you must submit documentation related to your active duty service which reflects the dates of service, character of service (honorable, general, etc.), and dates of impending separation. Additionally, disabled veterans and others eligible for 10-point preference (such as widows or mothers of eligible Veterans) must also submit an SF-15 "Application for 10 Point Veteran Preference" with required proof as stated on the form. Documentation is required to award preference. For more information on Veterans' Preference, please visit Feds Hire Vets - Veterans - Job Seekers - Veterans' Preference.
If you are relying on your education to meet qualification requirements:
Failure to provide all of the required information as stated in this vacancy announcement may result in an ineligible rating or may affect the overall rating.
All applicants are encouraged to apply online. To apply for this position, you must complete the full questionnaire and submit the documentation specified in the Required Documents section below. The complete application package must be submitted by 11:59 PM (ET) on 02/22/2023 to receive consideration. To preview the questionnaire click https://apply.usastaffing.gov/ViewQuestionnaire/11834226.
To begin, click Apply Online to create a USAJOBS account or log in to your existing account. Follow the prompts to select your USA JOBS resume and/or other supporting documents and complete the occupational questionnaire.
Click Submit My Answers to submit your application package.
NOTE: It is your responsibility to ensure your responses and appropriate documentation is submitted prior to the closing date.
To verify your application is complete, log into your USA JOBS account, https://my.usajobs.gov/Account/Login, select the Application Status link and then select the more information link for this position. The Details page will display the status of your application, the documentation received and processed, and any correspondence the agency has sent related to this application. Your uploaded documents may take several hours to clear the virus scan process. To return to an incomplete application, log into your USA JOBS account and click Update Application in the vacancy announcement. You must re-select your resume and/or other documents from your USA JOBS account or your application will be incomplete.
John D Dingell Department of Veterans Affairs Medical Center
4646 John R Street
Detroit, MI 48201
US
Next steps
Once your online application is submitted you will receive a confirmation notification by email. After we receive application packages (including all required documents) and the vacancy announcement closes, we will review applications to ensure qualification and eligibility requirements are met. After the review is complete, a referral certificate(s) is issued and applicants will be notified of their status by email. Referred applicants will be notified as such and may be contacted directly by the hiring office for an interview. All referred applicants receive a final notification once a selection decision has been made.
You may check the status of your application at any time by logging into your USA Jobs account and clicking on Applications. Information regarding your application status can be found in the USAJobs Help Center.
NOTE: Participation in the seasonal influenza program is a condition of employment and a requirement for all Department of Veterans Affairs Health Care Personnel (HCP). It is a requirement that all HCP to receive annual seasonal influenza vaccination or obtain an exemption for medical or religious reasons. Wearing a face mask is required when an exemption to the influenza vaccination has been granted. HCP in violation of this directive may face disciplinary action up to and including removal from federal service. HCP are individuals who, during the influenza season, work in VHA locations or who come into contact with VA patients or other HCP as part of their duties. VHA locations include, but are not limited to, VA hospitals and associated clinics, community living centers (CLCs), community-based outpatient clinics (CBOCs), domiciliary units, Vet centers and VA-leased medical facilities. HCP include all VA licensed and unlicensed, clinical and administrative, remote and onsite, paid and without compensation, full- and part-time employees, intermittent employees, fee basis employees, VA contractors, researchers, volunteers and health professions trainees (HPTs) who are expected to perform any or all of their work at these facilities. HPTs may be paid or unpaid and include residents, interns, fellows and students. HCP also includes VHA personnel providing home-based care to Veterans and drivers and other personnel whose duties put them in contact with patients outside VA medical facilities.
The Federal hiring process is set up to be fair and transparent. Please read the following guidance.
The following documents are accepted, and may be required if applicable to your eligibility and/or qualifications for this position. Please use this checklist to 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.
DD-214/ Statement of Service
Disability Letter (Schedule A)
Disability Letter (VA)
License
Other (1)
Other (2)
Other (3)
Professional Certification
Resume
Separation Notice (RIF)
SF-15
SF-50/ Notification of Personnel Action
Transcript
Veterans' Preference: When applying for Federal Jobs, eligible Veterans should claim preference for 5pt (TP), 10pt (CP/CPS/XP), or for Sole Survivor Preference (SSP) in the questionnaire. You must provide a legible copy of your DD214(s) which shows dates and character of service (honorable, general, etc.). If you are currently serving on active duty and expect to be released or discharged within 120 days you must submit documentation related to your active duty service which reflects the dates of service, character of service (honorable, general, etc.), and dates of impending separation. Additionally, disabled veterans and others eligible for 10-point preference (such as widows or mothers of eligible Veterans) must also submit an SF-15 "Application for 10 Point Veteran Preference" with required proof as stated on the form. Documentation is required to award preference. For more information on Veterans' Preference, please visit Feds Hire Vets - Veterans - Job Seekers - Veterans' Preference.
If you are relying on your education to meet qualification requirements:
Failure to provide all of the required information as stated in this vacancy announcement may result in an ineligible rating or may affect the overall rating.
All applicants are encouraged to apply online. To apply for this position, you must complete the full questionnaire and submit the documentation specified in the Required Documents section below. The complete application package must be submitted by 11:59 PM (ET) on 02/22/2023 to receive consideration. To preview the questionnaire click https://apply.usastaffing.gov/ViewQuestionnaire/11834226.
To begin, click Apply Online to create a USAJOBS account or log in to your existing account. Follow the prompts to select your USA JOBS resume and/or other supporting documents and complete the occupational questionnaire.
Click Submit My Answers to submit your application package.
NOTE: It is your responsibility to ensure your responses and appropriate documentation is submitted prior to the closing date.
To verify your application is complete, log into your USA JOBS account, https://my.usajobs.gov/Account/Login, select the Application Status link and then select the more information link for this position. The Details page will display the status of your application, the documentation received and processed, and any correspondence the agency has sent related to this application. Your uploaded documents may take several hours to clear the virus scan process. To return to an incomplete application, log into your USA JOBS account and click Update Application in the vacancy announcement. You must re-select your resume and/or other documents from your USA JOBS account or your application will be incomplete.
John D Dingell Department of Veterans Affairs Medical Center
4646 John R Street
Detroit, MI 48201
US
Next steps
Once your online application is submitted you will receive a confirmation notification by email. After we receive application packages (including all required documents) and the vacancy announcement closes, we will review applications to ensure qualification and eligibility requirements are met. After the review is complete, a referral certificate(s) is issued and applicants will be notified of their status by email. Referred applicants will be notified as such and may be contacted directly by the hiring office for an interview. All referred applicants receive a final notification once a selection decision has been made.
You may check the status of your application at any time by logging into your USA Jobs account and clicking on Applications. Information regarding your application status can be found in the USAJobs Help Center.
NOTE: Participation in the seasonal influenza program is a condition of employment and a requirement for all Department of Veterans Affairs Health Care Personnel (HCP). It is a requirement that all HCP to receive annual seasonal influenza vaccination or obtain an exemption for medical or religious reasons. Wearing a face mask is required when an exemption to the influenza vaccination has been granted. HCP in violation of this directive may face disciplinary action up to and including removal from federal service. HCP are individuals who, during the influenza season, work in VHA locations or who come into contact with VA patients or other HCP as part of their duties. VHA locations include, but are not limited to, VA hospitals and associated clinics, community living centers (CLCs), community-based outpatient clinics (CBOCs), domiciliary units, Vet centers and VA-leased medical facilities. HCP include all VA licensed and unlicensed, clinical and administrative, remote and onsite, paid and without compensation, full- and part-time employees, intermittent employees, fee basis employees, VA contractors, researchers, volunteers and health professions trainees (HPTs) who are expected to perform any or all of their work at these facilities. HPTs may be paid or unpaid and include residents, interns, fellows and students. HCP also includes VHA personnel providing home-based care to Veterans and drivers and other personnel whose duties put them in contact with patients outside VA medical facilities.
Fair and transparent
The Federal hiring process is set up to be fair and transparent. Please read the following guidance.
