Clarification from the agency

This job is open to current permanent Department of Veteran Affairs employees. Most recent SF50 required. Eligible applications will be reviewed and referred in the following order: 1) Facility Employees - Current, permanent JDD Medical Center employees 2) Other VA Employees - Current, permanent VA Employees located at other VA medical centers. NOTE: The 2-page Resume requirement does not apply to this position. For more information, refer to Required Documents below.

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Major duties include:

• 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; 8:00am to 4:30pm EST.
Telework: This position is currently authorized for telework - Location negotiable, incumbent must live within 50 mile radius of a VA Medical Center. To meet the Return to Office Executive Order requirements, selected candidates may be required to Return to Office. This will be discussed during the interview process.
Remote/Virtual: This position is currently designated as remote. Remote work is defined as full-time employment conducted outside of a VA facility or in VA-leased spaces. The option for remote work will be assessed continuously, and the selected individual may need to return to a VA office if required.
Functional Statement #: 91207-0, 91208-0, 91209-0, 91210-0
Relocation/Recruitment Incentives: Not Authorized
Permanent Change of Station (PCS): Not Authorized

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.
• Subject to background/security investigation.
• 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 dentification cards that are not REAL ID compliant cannot be utilized as an acceptable form of identification for employment.
• Participation in the seasonal influenza vaccination program is a requirement for all Department of Veterans Affairs Health Care Personnel (HCP).
• Complete all application requirements detailed in the "Required Documents" section of this announcement.

As a condition of employment for accepting this position, you will be required to serve a 1 or 2-year trial period during which we will evaluate your fitness and whether your continued employment advances the public interest. In determining if your employment advances the public interest, we may consider:

• your performance and conduct;
• the needs and interests of the agency;
• whether your continued employment would advance organizational goals of the agency or the Government; and
• whether your continued employment would advance the efficiency of the Federal service.

Upon completion of your trial period, your employment will be terminated unless you receive certification, in writing, that your continued employment advances the public interest.

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.
• English Language Proficiency. MRTs HIT must be proficient in spoken and written English, as required by 38 U.S.C. § 7403(f).
• 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

Reference: VA Handbook 5005/124, 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.

Continued in Education section below...

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.

** This position is currently authorized for telework - Location negotiable, incumbent must live within 50 mile radius of a VA Medical Center (not a clinic of CBOC). to meet the Return to Office Executive Order requirements, selected candidates may be required to Return to Office. This will be discussed during the interview process.**

Area of Consideration- Eligible applications will be reviewed and referred in the following order:

1. Current permanent VA employees of the facility
2. All other VA employees

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.

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.