This position is located in the Health Information Management
(HIM) section at the Tibor Rubin 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
Learn more about this agency
The Incumbent serves in the Health Information Management
Service (HIMS) in the VA Long Beach Healthcare System. VALBHCS
organization structure is large and complex. Incumbent serves as
technical expert in health record content and documentation
requirements. Incumbent is 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
Reviews records for adherence with CMS guidelines related to
student, resident supervision and attending physician presence and
documentation. Compiles reports to insure provider specific and
service compliance. Maintains a control system to ensure completion
of all inpatient and outpatient records in accordance with VA, The
Joint Commission, CMS and other regulatory agencies standards.
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.
The incumbent performs the quantitative and qualitative analysis
on both computer and paper-based health records. Consults with the
appropriate clinician( s) for clarification when conflicting or
ambiguous information appears in the health record
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
Responsible for expediting the completion of the health record
when the patient is transferred for care at another medical center,
for legal requests, regulatory agencies review, and reimbursement
Assesses the paper health record and electronic Computerized
Patient Record System (CPRS) for completeness and notes
deficiencies in the Access Chart Review database.
Tracks electronic signatures 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
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 complex weekly and monthly reports noting the status of
all incomplete/delinquent records and compliance reports and
submits the reports to the appropriate administrative and clinical
staff. Preforms analytical tasks associated with the resolution of
"filing" errors on reports uploaded by a transcription vendor. This
includes correctly identifying the patient the report belongs too
and filing/assigning it correctly. Duties includes the generation
of various statistical reports to track these errors. Makes
appropriate recommendations for changes or solutions and implements
appropriate recommendations for corrective action when authorized
so continued filing errors do not occur.
Identifies reviews, verifies, and corrects all statistical data
concerning medical transcription to maintain accuracy of medical
and statistical reports. Compares and resolves discrepancies
between daily Gains and Losses Sheet, Digital System Workload
Report and contract transcription logs as it relates to timeliness
and accuracy of dictated reports completed by medical transcription
Reviews health records for adherence with guidelines related to
resident supervision and attending physician presence. Works with
interdisciplinary staff to solve problems regarding proper health
record documentation and completion. Develops and compiles written
reports trending provider specific, service, and hospital
compliance reports regarding admission subsequent and discharge
notes. Obtains statistical information, applies statistical
formulas, and completes statistical reports for medical center
management. Prepares weekly and monthly reports noting the status
of all incomplete/delinquent health records and submits the reports
to the appropriate administrative and clinical staff. Participates
in routine and focused reviews for the purpose of identifying
problems and potential problems in record documentation as part of
the health record review process. Identifies and abstracts
information from health records for special studies and audits both
internal and external.
0675 Medical Records Technician
Conditions of Employment
- You must be a U.S. Citizen to apply for this job
- Designated and/or random drug testing may be required
- Selective Service Registration is required for males born after
- You may be required to serve a probationary period
- Subject to a background/security investigation
- Must be proficient in written and spoken English
- Selected applicants will be required to complete an online
a. Citizenship. Citizen of the United States.
b. 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.
(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.
(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
(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
a. English Language Proficiency. MRTs HIT must be proficient in
spoken and written English, as required by 38 U.S.C. 7403(f).
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. For employees who do not meet all the basic
requirements in this standard, but who met the qualifications
applicable to the position at the time they were appointed to it,
the following provisions apply:Such employees in an occupation that
does not require a licensure/certification/ registration, may be
reassigned, promoted, or demoted within the occupation, but will
not be promoted beyond the journey level or placed in supervisory
or managerial positions.Employees appointed on a temporary basis
prior to the effective date of the qualification standard may not
have their temporary appointment extended, or be reappointed on a
temporary or permanent basis, until they fully meet the basic
requirements of the standard.Employees initially grandfathered into
this occupation, who subsequently obtain additional education
and/or licensure/certification/registration that meet all the basic
requirements of this qualification standard, must maintain the
required credentials, as a condition of employment in the
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).
Medical Records Technician (HIT), GS-7 (Full Performance
(1) Experience. One year of experience equivalent to the next
lower grade level.
(2) Demonstrated Knowledge, Skills, and Abilities. In addition
to the experience above, the candidate must demonstrate all of the
(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.
Work Schedule: Monday through Friday, 8:00 a.m.- 4:30 p.m.
Financial Disclosure Report: Not required
References: VA Handbook 5005/124 PART II APPENDIX G59
The full performance level of this vacancy is GS-7.
May include but not limited to standing 2 hours per day, use of
both hands, use of fingers, sitting up to 8 hours per day.
IMPORTANT: A transcript must be submitted with your application
if you are basing all or part of your qualifications on
Note: Only education or degrees recognized by the U.S.
Department of Education from accredited colleges, universities,
schools, or institutions may be used to qualify for Federal
employment. You can verify your education here: http://ope.ed.gov/accreditation/.
If you are using foreign education to meet qualification
requirements, you must send a Certificate of Foreign Equivalency
with your transcript in order to receive credit for that education.
For further information, visit: