Medical Records Technician (Health Information Technician)

The Medical Record Technician (MRT) is assigned to the Health Information Management Section, Patient Business Service at the Chalmers P. Wylie VA Ambulatory Care Center (VAACC). Occupation involves technical work concerned with processing and maintenance of medical records. The MRT is responsible for a variety of tasks related to medical records: coding, abstracting, data entry, statistical reports, quality audits, consult tracking, data validation, Special Registry, record audit, etc.

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

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 (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:
    • Ability to communicate effectively with internal and external customers.
    • 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).
    • Knowledge of health record documentation guidelines and industry standards.
    • Ability to manage priorities and coordinate work to complete duties within required timeframes
    • 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 (Developmental Level 2)
  • 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:
    • 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

• Medical Records Technician (HIT), GS-7 (Full Performance Level)
  • Experience. One year of experience equivalent to the next lower level.
  • Demonstrated Knowledge, Skills, and Abilities. In addition to the experience above, the candidate must demonstrate all of the following KSAs:
    • 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 with 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, MEDICAL RECORDS TECHNICIAN (HEALTH INFORMATION TECHNICIAN) QUALIFICATION STANDARD GS-0675

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: A good portion of the work is sedentary but may require some walking, standing, bending, lifting, pulling, stretching and occasional lifting of boxes of records or documents. Work most often is performed in an office setting but may be performed throughout the facility in other settings. Incumbent must be safety conscious at all times.

Responsibilities:

Major duties include but are not limited to:

• Collects data from validation activities and audits that support continuity of patient care, budget/resource allocation, performance measurement, quality management, research, VA comparative analysis, and benchmarking.
• The MRT must have the ability to interpret and adapt health information guidelines that are not completely applicable to the work performed or have gaps in specificity.
• The MRT must have the ability to use judgment in completing assignments with incomplete or inadequate guidelines.
• The MRT must apply comprehensive knowledge of health information technology principles, concepts, and methodology in carrying out assignments, operations or procedures while performing different and unrelated processes and methods which include the ability to analyze the subject, phase or issues involved in each assignment.
• The nature of the work involves the full scope of reviews, analysis, problem identification and resolution, evaluations, coordination, monitoring and follow-up to ensure that the medical record contains sufficient information for regulatory requirements; are acceptable legal documents; are adequate for continuity of patient care; and support education and research needs.
• The MRT must have judgment, discretion, and a high degree of tact and negotiating skills to carry out the functions of the position.
• The MRT is organized, manages priorities and coordinates work in order to complete duties in an accurate and timely fashion. This includes the ability to follow-up on pending issues and demonstrates an understanding of the impact of incomplete work.
• The MRT communicates with individuals or groups who may be uncooperative, fearful, or skeptical, in order to obtain the desired effect, such as gaining compliance with established policies and regulations by persuasion or negotiation or gaining information by establishing rapport.

Work Schedule: Monday-Friday, 8:00am-4:30pm
Telework: Available(Ad-hoc)
Virtual: This is not a virtual position.
Functional Statement #: 91715-0,91716-0,91717-0,91565-0
Relocation/Recruitment Incentives: Not Authorized
Permanent Change of Station (PCS): Not Authorized
Financial Disclosure Report: Not required

Salary : $35,072 - $63,189