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MEDICAL RECORDS TECH (HIT)

Department of Veterans Affairs
Veterans Health Administration
Veterans Health Administration

Summary

This position is located in the Health Information Management (HIM) Section of Business Service at the VA Sierra Nevada Health Care System. MRTs Health Information Technician (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.

Overview

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Accepting applications
Location
1 vacancy in the following location:
Work site options
Telework eligible
No
Remote job
No
Relocation expenses reimbursed
No
Salary
$36,552 - $65,847 per year
Pay scale & grade
GS 4 - 7
Promotion potential
7
Pay scale and grade determines the salary of the job.
Work schedule
Full-time
Travel Required
Not required
Appointment type
Permanent
Occupations and job series
Supervisory status
No
Federal service type
This job is in the Excepted Service
Represented by a union
No
Drug test
No
Security clearance
Other
Position sensitivity and risk
Non-sensitive (NS)/Low Risk
Jobs require a background check and some require a security clearance. The type depends on the job.
Background check type
Financial disclosure required
No
Some jobs require financial disclosure to identify conflicts of interests.
Announcement number
CBSW-13109491-27-HR
Control number
892594700

This job is open to

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Clarification from the agency

NOTE: The 2-page Resume requirement does not apply to this position.

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Duties

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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.

Identifies health record deficiencies, tracks deficiencies and ensures that the appropriate individual completes their deficiencies. The incumbent 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.

Work Schedule: Monday through Friday 8:00 Am to 4:30 PM
Telework: Telework, if approved, would be on an AD-HOC basis.
Virtual: This is not a virtual position.
Functional Statement #: 40851-0
Relocation/Recruitment Incentives: Not Authorized
Permanent Change of Station (PCS): Not Authorized
Financial Disclosure Report: Not required

Requirements

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Conditions of employment

  • 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.
  • 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

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:

  • United States Citizenship: Non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy.
  • 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.
  • English Language Proficiency. MRTs HIT must be proficient in spoken and written English, as required by 38 U.S.C. ยง 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).

Grade Determinations:

Medical Records Technician (HIT), GS-4
Experience or Education. None beyond basic requirements.

Medical Records Technician (HIT), GS-5

Experience: One year of creditable experience equivalent to the next lower grade level GS-4; OR Education: Successful completion of 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 and physiology, legal aspects of health care, and introduction to health records). * You must provide a copy of your transcripts with your job application. 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. 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

Experience: One year of experience equivalent to the next lower grade level (GS-6). 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 Part II Appendix G59

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: The work is mostly sedentary; however, some bending, stretching, walking, carrying less than 15 pounds and using a computer terminal are required. No special physical characteristics or special physical abilities are required

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.

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.

Candidates should be committed to improving the efficiency of the Federal government, passionate about the ideals of our American republic, and committed to upholding the rule of law and the United States Constitution.

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, 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.

Veterans Health Administration

OUR MISSION: To fulfill President Lincoln's promise "To care for those who have served in our nation's military and for their families, caregivers, and survivors" - by serving and honoring the men and women who are America's Veterans. How would you like to become a part of a team providing compassionate whole health care to Veterans?

Welcome to Reno/Tahoe! Nestled at the foot of the Sierra Nevada mountains with easy access to Lake Tahoe, Reno is ideal for your inner adventurer. Enjoy kayaking, paddle boarding, and hiking in the summer, sledding and snowshoeing in the winter, or head on up to the slopes to ski or snowboard where many Olympic athletes train. Check out our many hip restaurants and shops in Midtown, or take a walk by the river downtown and stop in at a dog friendly brewery. We are the home of a dynamic art scene and many iconic events: Artown, Hot August Nights, Street Vibrations, Rib Cook-off, Great Reno Balloon Races, Reno Rodeo, and the National Championship Air Races. Summers can get hot, but the humidity is low, and there is no state income tax in Nevada! For more information click: Special Events.

We encourage you to consider VA employment in Reno, NV. We offer both a mission you can put your heart into and a home for fun, new experiences. Join a team that values a healthy home/work life balance and be rewarded by your role in keeping the promise to those who served." For more information click Recreation.

Agency contact information

Havel Respes
Phone
415-221-4810 X23728
Email
havel.respes@va.gov
Address
VA Sierra Nevada Health Care System
975 Kirman Avenue
Reno, NV 89502
US

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