MEDICAL RECORDS TECH (HIT)
MEDICAL RECORDS TECHNICIAN (HEALTH INFORMATION TECHNICIAN) This position is located in the Health Information Management (HIM) section at the Northern California VA Medical Center. MRTs 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. Some of the duties include, but are not limited to:
Analyze health records for accuracy, completeness, timeliness, consistency, and compliance (e.g., scanned, uploaded, use of correct titles, linked to correct encounters, etc.) with 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. Communicate regularly with staff at various levels of the organization regarding delinquent health records and notify individual clinical providers regarding incomplete medical records. Prepare complex reports, calculate department statistics, note the status of all incomplete/delinquent records and submit reports to the appropriate administrative and clinical staff and committees/leadership to ensure deficiencies are resolved and completed appropriately. Serve as the expert resource for clinical staff and assist clinical providers with completion or correction of their health record documentation. Conduct reviews of incomplete records for individuals clearing the facility. Coordinate the use of medical speech recognition/transcription and monitor, verify, troubleshoot, correct, and/or upload all transcription/medical speech recognition to maintain completeness and accuracy of health records. Serve as the technical expert in health record content and documentation requirements. Work Schedule:
Monday - Friday, 8am to 4:
30pm Fair Labor Standards Act (FLSA):
Non-Exempt Bargaining Unit Position:
Yes Relocation Expenses:
Relocation expenses are not authorized for this position. Financial Disclosure Report:
Not required 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. Must be proficient in spoken and written English. Experience and Education. One year of experience that indicates knowledge of medical terminology, anatomy, physiology, and a general understanding of health records? Six months of the required one year of experience must have provided the knowledge, skills, and abilities (KSAs) needed to perform Medical Record Technician (HIT) work. OR 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 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 Equivalent combinations of experience and education:
(1) Six months of creditable experience that indicates knowledge of medical terminology, privacy and release of information, the health record, and on year above high school with a minimum of six semester hours of health information technology/health information management. (2) 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. (TRANSCRIPTS REQUIRED) GRADE DETERMINATION:
In addition to the BASIC REQUIREMENTS, the following criteria must be met in order to qualify for each grade level. GS-4:
Entry Level Experience or Education:
None beyond Basic Requirements. GS-5:
Developmental Level 1 Experience or Education. One year of experience comparable to the GS-4 grade level of MRT (HIT) OR a bachelor's degree from an accredited 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). In addition to the experience above, you must demonstrate the following knowledge, skills, and abilities (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. GS-6:
Developmental Level Experience. Must have at least one year of specialized experience equivalent to the GS-5 grade level of MRT (HIT). In addition to the experience above, you must demonstrate the following Knowledge, Skills, and Abilities (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 GS-7:
Full Performance Level Experience. Must have at least one year of specialized experience equivalent to the GS-6 grade level of MRT (HIT). In addition to the experience above, you must demonstrate the following Knowledge, Skills, and Abilities (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. 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). Reference:
VA Handbook 5005, Part II, Appendix G59, Medical Record Technician (Health Information Technician) Qualification Standard. 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:
The duties and responsibilities of the position require some mobility between various clinic areas in separate building locations sites, but generally the job is sedentary with some standing, stooping, reaching and lifting up to 20 pounds. The employee is required to work with computer equipment at 75% of the time which impacts on hand and wrist motions. Work must be performed with a high degree of accuracy. Must have emotional and mental stability and demonstrate ability to work under pressure with numerous interruptions.
Estimated Salary: $20 to $28 per hour based on qualifications.
Analyze health records for accuracy, completeness, timeliness, consistency, and compliance (e.g., scanned, uploaded, use of correct titles, linked to correct encounters, etc.) with 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. Communicate regularly with staff at various levels of the organization regarding delinquent health records and notify individual clinical providers regarding incomplete medical records. Prepare complex reports, calculate department statistics, note the status of all incomplete/delinquent records and submit reports to the appropriate administrative and clinical staff and committees/leadership to ensure deficiencies are resolved and completed appropriately. Serve as the expert resource for clinical staff and assist clinical providers with completion or correction of their health record documentation. Conduct reviews of incomplete records for individuals clearing the facility. Coordinate the use of medical speech recognition/transcription and monitor, verify, troubleshoot, correct, and/or upload all transcription/medical speech recognition to maintain completeness and accuracy of health records. Serve as the technical expert in health record content and documentation requirements. Work Schedule:
Monday - Friday, 8am to 4:
30pm Fair Labor Standards Act (FLSA):
Non-Exempt Bargaining Unit Position:
Yes Relocation Expenses:
Relocation expenses are not authorized for this position. Financial Disclosure Report:
Not required 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. Must be proficient in spoken and written English. Experience and Education. One year of experience that indicates knowledge of medical terminology, anatomy, physiology, and a general understanding of health records? Six months of the required one year of experience must have provided the knowledge, skills, and abilities (KSAs) needed to perform Medical Record Technician (HIT) work. OR 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 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 Equivalent combinations of experience and education:
(1) Six months of creditable experience that indicates knowledge of medical terminology, privacy and release of information, the health record, and on year above high school with a minimum of six semester hours of health information technology/health information management. (2) 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. (TRANSCRIPTS REQUIRED) GRADE DETERMINATION:
In addition to the BASIC REQUIREMENTS, the following criteria must be met in order to qualify for each grade level. GS-4:
Entry Level Experience or Education:
None beyond Basic Requirements. GS-5:
Developmental Level 1 Experience or Education. One year of experience comparable to the GS-4 grade level of MRT (HIT) OR a bachelor's degree from an accredited 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). In addition to the experience above, you must demonstrate the following knowledge, skills, and abilities (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. GS-6:
Developmental Level Experience. Must have at least one year of specialized experience equivalent to the GS-5 grade level of MRT (HIT). In addition to the experience above, you must demonstrate the following Knowledge, Skills, and Abilities (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 GS-7:
Full Performance Level Experience. Must have at least one year of specialized experience equivalent to the GS-6 grade level of MRT (HIT). In addition to the experience above, you must demonstrate the following Knowledge, Skills, and Abilities (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. 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). Reference:
VA Handbook 5005, Part II, Appendix G59, Medical Record Technician (Health Information Technician) Qualification Standard. 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:
The duties and responsibilities of the position require some mobility between various clinic areas in separate building locations sites, but generally the job is sedentary with some standing, stooping, reaching and lifting up to 20 pounds. The employee is required to work with computer equipment at 75% of the time which impacts on hand and wrist motions. Work must be performed with a high degree of accuracy. Must have emotional and mental stability and demonstrate ability to work under pressure with numerous interruptions.
- Department:
0675 Medical Records Technician - Salary Range:
$34,012 to $68,581 per year
Estimated Salary: $20 to $28 per hour based on qualifications.
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