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Summary This position is located in the Health Information Management (HIM) section at the G. V. (Sonny) Montgomery 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. Responsibilities If you are not a current permanent VA employee or Federal employee from other federal agencies, you should apply under CBST-12769165-25-LS The duties of the Medical Records Technician (Health Information Technician) include, but are not limited to: Serves as technical expert in health record content and documentation requirements. Performs quantitative and qualitative reviews of health record documentation for ongoing regulatory reviews and deficiency analysis. Ensures that all patient care data entered in the electronic health record (EHR) is accurate, timely, and complete. Adheres to established documentation requirements as outlined by The Joint Commission (TJC) regulations, Veterans Health Administration (VHA) guidelines, as well as medico-legal requirements. Reviews health records for adherence with the Centers for Medicare and Medicaid Services (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 health records in accordance with VHA, TJC, CMS and other regulatory agencies standards. Reviews health records to ensure that all health records contain sufficient information to meet medico-legal requirements, to ensure continuity of patient care, and to support education and research needs. Notifies clinicians of missing, incomplete, or inaccurate information in their signature blocks (e.g., missing or inaccurate credentials). Assists clinicians with completion of delinquent/incomplete health records. Assesses the health record for completeness, identifies health record deficiencies, tracks deficiencies, and ensures that the appropriate individuals complete their deficiencies. Notates documentation deficiencies in the appropriate deficiency monitoring application. Tracks unsigned/uncosigned notes (e.g., progress notes, operative reports, discharge summaries, etc.) and encounters without associated progress notes, and communicates these deficiencies to clinical staff for completion. Performs analytical tasks associated with the resolution of "filing" errors on reports. Makes appropriate recommendations for changes or solutions and implements appropriate recommendations for corrective action when authorized so continued filing errors do not occur. Works with interdisciplinary staff to solve problems regarding proper health record documentation and completion. Consults with the appropriate clinician(s) for clarification when conflicting or ambiguous information appears in the health record documentation. Participates in routine and focused reviews for the purpose of identifying problems and potential problems in health 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. Work Schedule: Monday - Friday, 8:00 am - 4:30 pm, subject to change based on the needs of the facility. Telework: Not Available Virtual: This is not a virtual position. Functional Statement #: 01434F, 01435F, 01436F, 01437F Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized Requirements Conditions of Employment You must be a U.S. Citizen to apply for this job. Selective Service Registration is required for males born after 12/31/1959. Must be proficient in written and spoken English. You may be required to serve a trial period. Subject to background/security investigation. Selected applicants will be required to complete an online onboarding process. Acceptable form(s) of identification will be required to complete pre-employment requirements (https://www.uscis.gov/i-9-central/form-i-9-acceptable-documents). Effective May 7, 2025, driver's licenses or state-issued dentification cards that are not REAL ID compliant cannot be utilized as an acceptable form of identification for employment. Must pass pre-employment medical evaluation. Participation in the seasonal influenza vaccination program is a requirement for all Department of Veterans Affairs Health Care Personnel (HCP). 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. (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. The following educational/training substitutions are appropriate for combining education and creditable experience: (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. 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): (1) Experience or Education. None beyond basic requirements. (2) Assignment. Employees at this level serve as entry level MRTs HIT, and receive close supervision from the supervisory MRT HIT or designee. MRTs HIT 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 accrediting bodies. They perform health record review activities to satisfy external accreditation requirements and medical center performance measures. They monitor, verify, correct, and upload all transcription/medical speech recognition to maintain completeness and accuracy of health records. 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). 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 time frames. 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 Experience. One year of experience equivalent to the next lower grade level. This is a developmental level for MRT(HITs). The MRT (HIT) at this level receives guidance from the supervisory MRT (HIT) or designee, for more complex health records. The MRT HIT analyzes, abstracts, maintains, extracts and compiles information from the health record, working under the review of the supervisor. They 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. They coordinate and/or perform health record review activities to satisfy external accreditation requirements and medical center performance measures. The MRT HIT notifies clinical providers regarding incomplete health records. They assist clinical providers regarding completeness of their health record documentation, and the correction of health records. They conduct reviews of incomplete records for individuals clearing the facility. They create and monitor reports to ensure that deficiencies are resolved and completed appropriately. They monitor, verify, correct, and/or upload all transcription/medical speech recognition to maintain completeness and accuracy of health records. MRTs HIT serve as the technical experts in health record content and documentation requirements. 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 Determination for Medical Records Technician (HIT), GS-7 (Full Performance Level) Continued in Education Section. Reference: For more information on this qualification standard, please visit https://www.va.gov/ohrm/QualificationStandards/. 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: Physical Demands: Physical aspects associated with work required of this assignment are typical for this occupation, see duty section for essential duties of this position. May require standing, lifting, carrying, sitting, stooping, bending,, pulling, and pushing. May be required to wear personal protective equipment and undergo annual TB screening or testing as conditions of employment. Work Environment: Work is performed in an office clinic setting with minimal risks that requires normal safety precautions; the area is adequately lighted heated and ventilated. However, the work environment requires someone with the ability to handle several tasks at once and sometimes stressful situations. Education GS-7 Grade Determination Continued. Medical Records Technician (HIT), GS-7 (Full Performance Level) Experience. One year of experience equivalent to the next lower grade level. This is considered the journey level for MRTs HIT. MRTs HIT at this level review, analyze, abstract, maintain, extract, and compile information from the health record independently with minimal supervision. They 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. They also coordinate and/or perform health record review activities to satisfy external accreditation requirements and medical center performance measures. They communicate regularly with staff at various levels of the organization regarding delinquent health records, and notify individual clinical providers regarding incomplete medical records. MRTs HIT 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. They serve as the expert resource for clinical staff and assist clinical providers with completion or correction of their health record documentation. They conduct the review of incomplete records for individuals clearing the facility. MRTs HIT 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. They serve as the technical expert in health record content and documentation requirements. 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. 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: https://sites.ed.gov/international/recognition-of-foreign-qualifications/. Additional Information During the application process you may have an option to opt-in to make your resume available to hiring managers in the agency who have similar positions. Opting in does not impact your application for this announcement, nor does it guarantee further consideration for additional positions. This job opportunity announcement may be used to fill additional vacancies. This position is in the Excepted Service and does not confer competitive status. VA encourages persons with disabilities to apply. The health-related positions in VA are covered by Title 38, and are not covered by the Schedule A excepted appointment authority. If you are unable to apply online or need an alternate method to submit documents, please reach out to the Agency Contact listed in this Job Opportunity Announcement. Under the Fair Chance to Compete Act, the Department of Veterans Affairs prohibits requesting an applicant's criminal history prior to accepting a tentative job offer. For more information about the Act and the complaint process, visit Human Resources and Administration/Operations, Security, and Preparedness (HRA/OSP) at The Fair Chance Act.