Clarification from the agency

Open to current, permanent employees of the Richard L. Roudebush VA Medical Center & subsidiary CBOCs; and past/current/upcoming VA Health Professional Trainees (HPTs) of related educational field.

Videos

The duties in this position are primarily advisory and technical in nature. The major duties of this position include, but are not limited to:

• The HITs review, analyze, abstract, compile maintain and extract information from the electronic medical record.
• The employee keeps abreast of work progress, establishes work priorities and makes necessary adjustments to comply with new or revised procedures of the units. He/she must have working knowledge of all handbook regulations, instructions, VISN Policies, directives, policies, etc. pertinent to the functions of the unit.
• Incumbent is responsible for ensuring that all patient care data entered in Vista and CPRS is accurate, timely and completed. Adheres to established documentation requirements as outlined by The Joint Commission regulations, Veterans Health Administration guidelines, as well as medical -legal requirements.
• He/she prepares complex weekly and monthly reports noting the status of all incomplete /delinquent health records, compliance reports and submits the reports to the appropriate administrative and clinical staff such as: Weekly service deficiency reports, Monthly Copy & Paste Monitor, Monthly Joint Commission Report as well as any other requested reports.
• The incumbent works with physicians (staff, fellows, resident, and interns), nurses, clinic clerks, and ward secretaries, clinical bed service personnel, ancillary service personnel and others in-services that furnish technical guidance of the medical record, including its components and sequence; VISTA TIU Package and deficiency tracking procedures.
• 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.

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).
• Selected applicants will be required to complete an online onboarding process. Acceptable form(s) of identification will be required to complete pre-employment requirements ( https://www.uscis.gov/i-9-central/form-i-9-acceptable-documents). Effective May 7, 2025, driver's licenses or state-issued identification cards that are not REAL ID complaint cannot be utilized as an acceptable form of identification for employment.

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.

• Citizenship. 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.
• 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,
• 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,
• 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.
• Grandfathering Provision. All persons employed in VHA as a MRT HIT, on the effective date of this qualification standard, are considered to have met all qualification requirements for the grade held, including positive education and licensure/certification/ registration that are part of the basic requirements of the occupation.

• 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 7 improvement of health records.
• (f) Ability to work independently and utilize problem-solving techniques in the accomplishment of work.

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.

NOTE: You must include qualifying specialized experience in mm/yyyy to mm/yyyy format on your resume and indicate Full-Time or Part-Time (if Part-time, must include # of hours worked per week). AND, if you have held a Government position, that position's grade level MUST be listed on your resume

Narrative responses are not required at this time. If you are referred for consideration, you may be asked to submit additional job related information, which may include, but not limited to; responses to the knowledge, skills and abilities; completion of a work sample, and/or contact for an interview. Your resume and/or supporting documentation will be verified. Please follow all instructions carefully. Errors or omissions may affect your rating or 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.