Clarification from the agency

This announcement is open to all U.S. Citizens and current Federal employees of other agencies. Current permanent VA employees, please apply under announcement number CBSY-11711022-23-KA to receive first consideration.

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The VA Midwest Health Care Network advocates for a Whole Health System of care in each of the Medical Centers. This is an approach to healthcare that empowers and equips people to take charge of their health and well-being and live their lives to the fullest. As an employee operating in a Whole Health System of care, you will operate in a model with three core elements, seeking to create a personalized health plan for each Veteran. This is done in the context of healing relationships and healing environments and a connection back to the Veteran's community. This aligns with the Veterans Health Administration (VHA) Mission Statement to Honor America's Veterans by providing exceptional health care that improves their health and well-being.

MRTs HIT analyze health records for accuracy, completeness, timeliness, consistency, and compliance with HIM industry standards, policies, procedures, time frames, laws, regulations, and accreditation requirements. They also coordinate and/or perform health record review activities to satisfy external accreditation requirements and medical center performance measures. The HIT performs functions to correct erroneous documentation issues such as changing note titles, reassigning notes to appropriate appointments, deleting notes upon request, correcting appointments, performing data entry of coding data, etc. They communicate regularly with staff at various levels of the organization regarding incomplete encounters and delinquent health records, MRTs HIT prepare multiple reports daily to notify clinical services and staff of outstanding records/encounters and perform various functions within their scope to resolve delinquencies. The MRT HIT serves as the expert resource regarding encounter forms and provides education for clinical staff regarding the encounter form software and completion of encounters. The MRT HIT is responsible for uploading appropriate encounter forms, ensuring all encounter forms being used are up to date and attached to the appropriate clinic location.

• Responsible for ensuring that the patient care data entered in VistA and/or Computerized Patient Record System (CPRS) is accurate, timely, and completed. Incumbent prepares reports and reviews daily Action Required reports to ensure encounters are closed out appropriately for accurate workload capture and adherence to Veterans Health Administration (VHA) guidelines.
• Performs corrections on data entered into VistA and/or CPRS to ensure accurate, and timely data capture. These corrections include various functions such as changing note titles, reassigning notes, attaching notes to consults, correcting incorrect appointments, entering coding data and deleting notes. Incumbent ensures all VHA guidelines and facility policies are followed in performing these functions.
• Performs special compliance audits to ensure appropriate clinic selection, note title and code category are selected to ensure appropriate first party and third party billing is generated. Incumbent corrects errors as needed as needed.
• Serves as the facility expert regarding encounter forms. Incumbent provides training for providers and clinical staff responsible for completion of encounter forms. Incumbent works directly with the service lines and coding staff in developing, maintaining, revising and uploading the electronic encounter forms.
• Prepares and works daily action required reports and communicates with all service lines to ensure timely completion. Incumbent will problem solve any issues with incomplete encounters to correct as appropriate.
• 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.
• Communicates issues to service lines and clinical staff for correction. Notification can be in person, internal e-mail, telephone, or through other normal routing system. 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 multiple daily reports noting the status of incomplete notes, encounters and delinquent records and uploads to appropriate shared site for administrative and clinical staff.
• Works with interdisciplinary staff to solve problems regarding proper health record documentation and completion. Incumbent assists coding staff with issues identified for appropriate third party billing.

Work Schedule: Monday - Friday, 7:00 a.m.-3:30 p.m.
Telework: Available - Regular and recurring
Virtual: This is not a virtual position.
Relocation/Recruitment Incentives: Not authorized
Permanent Change of Station (PCS): Not authorized
Financial Disclosure Report: Not required

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.
• Must pass pre-employment physical examination.
• 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 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. § 7403(f)

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.

All qualifying experience you possess must be clearly described in your application package. We will not make assumptions when reviewing applications. Failure to demonstrate your experience in your resume may result in disqualification. It is strongly recommended that you write to each KSA in your application package.

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: This position is mainly sedentary and will be performed in an office setting.

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.

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.