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Medical records Tech (hit)

Company: Department of Veterans Affairs
Location: Long Beach
Posted on: May 3, 2021

Job Description:

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Duties

Summary

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 regulatory compliance.

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Responsibilities

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 medical-legal requirements.

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 documentation.

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.

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 purposes.

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 contractor.

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.

Travel Required

Not required

Supervisory status

No

Promotion Potential

7

  • Job family (Series)

0675 Medical Records Technician

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  • Requirements

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Requirements

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 12/31/1959
  • 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 onboarding process

Qualifications

BASIC REQUIREMENTS.

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. OR,

(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 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.

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 occupation.

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 REQUIREMENTS:

Medical Records Technician (HIT), GS-7 (Full Performance Level)

(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 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 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.

Physical Requirements:

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.

Education

IMPORTANT: A transcript must be submitted with your application if you are basing all or part of your qualifications on education.

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: http://www.ed.gov/about/offices/list/ous/international/usnei/us/edlite-visitus-forrecog.html.

Keywords: Department of Veterans Affairs, Long Beach , Medical records Tech (hit), Other , Long Beach, California

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