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Summary This position is located in the Health Information Management (HIM) section at the Atlanta VA Health Care System. 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. Responsibilities Medical Records Technician (Health Information Technician) (MRT HIT) performs incomplete health record analysis; review, analyze, abstract, maintain, extract, and compile information from the health record; and check for accuracy, completeness, and timeliness of the health record and monitor and report for regulatory compliance. The following major functions and responsibilities are for the full performance level (GS-07) for this position. Employees at lower grade level will receive supervision/guidance from the supervisory MRT HIT or designee. Major functions and responsibilities include but are not limited to: Serve as technical expert in health record content and documentation requirements Review records for adherence with CMS guidelines related to student, resident supervision and attending physician presence and documentation Review 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 Perform the quantitative and qualitative analysis on both computer and paper based health records Identify health record deficiencies, track deficiencies and ensure that the appropriate individual completes their deficiencies Expedite 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 Assess the paper health record and electronic Computerized Patient Record System (CPRS) for completeness and note deficiencies Track electronic signatures and documents deficiencies and communicates these deficiencies to clinical staff for correction Prepare complex weekly and monthly reports noting the status of all incomplete/delinquent records and compliance reports and submit the reports to the appropriate administrative and clinical staff Preform analytical tasks associated with the resolution of "filing" errors on reports uploaded by a transcription vendor Identify, review, verify, and correct all statistical data concerning medical transcription to maintain accuracy of medical and statistical reports Review health records for adherence with guidelines related to resident supervision and attending physician presence Work with interdisciplinary staff to solve problems regarding proper health record documentation and completion Develop and comply written reports trending provider specific, service, and hospital compliance reports regarding admission subsequent and discharge notes Prepare weekly and monthly reports noting the status of all incomplete/delinquent health records and submit the reports to the appropriate administrative and clinical staff Preform analytical tasks associated with the resolution of "filing" errors on reports uploaded by a transcription vendor Identify, review, verify, and correct all statistical data concerning medical transcription to maintain accuracy of medical and statistical reports Review health records for adherence with guidelines related to resident supervision and attending physician presence Work with interdisciplinary staff to solve problems regarding proper health record documentation and completion Develop and comply written reports trending provider specific, service, and hospital compliance reports regarding admission subsequent and discharge notes Prepare weekly and monthly reports noting the status of all incomplete/delinquent health records and submit the reports to the appropriate administrative and clinical staff Work Schedule: Monday - Friday 08:00 am to 04:30 pm Financial Disclosure Report: Not required Requirements Conditions of Employment 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: (1) 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 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). (UNOFFICIAL TRANSCRIPT REQUIRED: If you do not submit your transcript, your application will not be reviewed.) OR, (3) Experience/Education Combination. 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: (a) 6 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 6 semester hours of health information technology/health information management; (b) 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 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. English Language Proficiency. MRTs HIT must be proficient in spoken and written English, as required by VA Policy.. Medical Records Technician (HIT), GS-6: Experience. 1 year of experience equivalent to the next lower grade level (GS-5). Qualifying specialized experience is a developmental level MRT HIT experience analyzing health records for accuracy, completeness, timeliness, consistency, and compliance with HIM industry standards, policies, procedures, laws, regulations, and accreditation requirement; performing health record review activities to satisfy external accreditation requirements and medical center performance measures; creating and monitoring reports to ensure that deficiencies are resolved and completed appropriately; monitoring, verifying, correcting, and/or uploading all transcription/medical speech recognition to maintain completeness and accuracy of health records; notifying clinical providers regarding incomplete health records; and assisting clinical providers regarding completeness of their health record documentation. AND Demonstrated Knowledge, Skills, and Abilities. In addition to the experience above, the candidate must demonstrate all of the following KSAs: See Demonstrated KSAs under 'Education.' Medical Records Technician (HIT), GS-7 (Full Performance Level): Experience. 1 year of experience equivalent to the next lower grade level (GS-6). Qualifying specialized experience is a developmental level MRT HIT experience analyzing, abstracting, maintaining, extracting and compiles information from the health record, working under the review of the supervisor; analyzing health records for accuracy, completeness, timeliness, consistency, and compliance with HIM industry standards, policies, procedures, laws, regulations, and accreditation requirements; coordinating and/or performing health record review activities to satisfy external accreditation requirements and medical center performance measures; notifying clinical providers regarding incomplete health records; assisting clinical providers regarding completeness of their health record documentation, and the correction of health records; conducting reviews of incomplete records for individuals clearing the facility; creating and monitoring reports to ensure that deficiencies are resolved and completed appropriately; monitoring, verifying, correcting, and/or uploading all transcription/medical speech recognition to maintain completeness and accuracy of health records; and serving as the technical experts in health record content and documentation requirements. AND Demonstrated Knowledge, Skills, and Abilities. In addition to the experience above, the candidate must demonstrate all of the following KSAs: See Demonstrated KSAs under 'Education.' References: VA Handbook 5005/124, Part II, Appendix G59. Medical Records Technician (HIT) Qualification Standard GS-0675. This can be found in the local Human Resources Office. 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 work is sedentary, but may require walking, bending, standing, and /or carrying of light items such as files and manuals. The work does not require any special physical effort or ability. 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. Experience 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. To be creditable, experience must be documented on the application or resume and verified in an employment reference, or through other independent means. Part-time experience as a MRT HIT is creditable according to its relationship to the full-time workweek. For example, a MRT HIT would receive one week of full-time credit for each two weeks of half-time work. (NOTE: EXPERIENCE - The experience must be supported by your resume to be creditable. UNOFFICIAL TRANSCRIPT REQUIRED - If you do not submit your transcript, your application will not be reviewed.) Demonstrated Knowledge, Skills, and Abilities for Grade GS-05, 06, and 07GS-05 Demonstrated Knowledge, Skills, and Abilities. In addition to the experience or education above, the candidate must demonstrate all of the following KSAs: See Demonstrated KSAs under 'Education' section.(a) Ability to communicate effectively with internal and external customers; (b) 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); (c) Knowledge of health record documentation guidelines and industry standards; (d) Ability to manage priorities and coordinate work to complete duties within required timeframes; (e) Ability to apply knowledge of medical terminology and human anatomy to fully understand the content of a health record GS-06 Demonstrated Knowledge, Skills, and Abilities. In addition to the experience above, the candidate must demonstrate all of the following KSAs: (a) Ability to navigate efficiently through the health record to locate needed information; (b) Ability to analyze health record documentation to ensure compliance with guidelines and industry standards; (c) Skill in investigating potential health record errors and making corrections, when appropriate; (d) Skill in interpreting and applying health information guidelines and using judgment to complete assignments; (e) Ability to follow up on incomplete health record documentation GS-07 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. Additional Information This job opportunity announcement may be used to fill additional vacancies. This position is in the Excepted Service and does not confer competitive status.