MEDICAL RECORDS TECH (ROI)

<p>This position is located in the Health Information Management (HIM) section at the Wm. S. Middleton Memorial Veterans Hospital. The Release of Information (ROI) technicians reviews and processes requests for patient protected health information (PHI,) in accordance with all applicable Federal laws, rules, and regulations regarding release of health information.</p><h3>Major Duties</h3><p>DUTIES GS-0675-04: A. The incumbent processes all incoming requests to the facility for Release of Information (ROI) along with information required by the VA Regional Office through the Automated Medical Information Exchange (AMIE), and Social Security Administration. B. Evaluates validity of each request. Determines which information is to be released in compliance with existing laws (Privacy Act of 1974, Freedom of Information Act, and Health Insurance Portability and Accountability Act). Ensures that proper authorization exists before release is made. Processes the request to the requesting agency or individual. Inputs all requests into the ROI computer package for logging and tracking of these requests. C. Receives and directs callers and visitors. Receives and/or gives out forms, and assists visitors and/or callers with the completion of forms or documents. Responds to questions from patients concerning services. Provides advisory and technical assistance to patients, administrative staff and professional staff regarding release of information. Inquiries vary widely and information given requires explanation of office functions, describing specific requirements, providing basic instructions, or a similar degree of detail. D. Searches records or files to compose responses, including electronic searches to retrieve and summarize hard-to-locate data. Locates materials that would verify information given. E. Employee composes responses to routine requests for release of patient information. Selects and compiles information from health records and prepares correspondence, typically using standard form or standard formats for letters. Ensures the information released is limited to what is specifically authorized and to the person or agency designated to receive it. GS-0675-05: A. The duties in this position are primarily advisory and technical in nature. Incumbent is responsible for evaluating the adequacy of each completed authorization form. Screens each request for information to determine urgency and assures that most urgent requests are completed fist using established priority systems. Personally greets veterans /visitor, assists them in determining the exact nature of the request and whether the information requested can be released. B. Applies public laws, rules, regulations and exclusions governing confidentiality of the medical record, including the Privacy Act, Freedom of Information Act and 38 U.S.C. 7332 governing the release of records containing information regarding the treatment of or referral for drug and/or alcohol abuse, Sickle Cell Anemia and infection with Human Immunodeficiency Virus (HIV). C. The incumbent processes all incoming requests to the facility for Release of Information (ROI) along with information required by the VA Regional Office through the Automated Medical Information Exchange (AMIE). D. Evaluates validity of each request. Determines which information is to be released in compliance with existing laws (Privacy Act of 1974, Freedom of Information Act, and Health Insurance Portability and Accountability Act). Ensures that proper authorization exists before release is made. Processes the request to the requesting agency or individual. Inputs all requests into the ROI computer package for logging and tracking of these requests. E. Receives and directs callers and visitors. Receives and/or gives out forms, and assists visitors and/or callers with the completion of forms or documents. Responds to questions from patients concerning services. Provides advisory and technical assistance to patients, administrative staff and professional staff regarding release of information. Inquiries vary widely and information given requires explanation of office functions, describing specific requirements, providing basic instructions, or a similar degree of detail. F. Searches records or files to compose responses, including electronic searches to retrieve and summarize hard-to-locate data. Locates materials that would verify information given. G. Reviews paper and computerized health records (i.e., scanned notes, reports, special tests, etc.) to identify material to be photocopied/printed/written to electronic media and released. H. Employee composes responses to routine requests for release of patient information. Selects and compiles information from health records and prepares correspondence, typically using standard form or standard formats for letters. Ensures the information released is limited to what is specifically authorized and to the person or agency designated to receive it.</p><h3>Requirements</h3>I. Composes detailed explanations in response to correspondence received, arranging information into logical sequence and appropriate format and choosing appropriate words and expressions to convey the desired tone. Determines extent and tone of replies independently. J. Resolves conflicting or inconsistent information found on initial requests. This involves dealing with patients and/or third parties to resolve discrepancies, sorting out errors and reconstructing past transactions, cases or events, or finding alternative sources of information. K. Processes Social Security requests for health information using ROI software. Downloads VistA Imaging documents and ROI software documents onto a secure Network Drive. Accesses the secure Social Security Web page and uploads the documents to the Web portal. Transfers the confirmation codes to the ROI software package and closes the request(s) in both the ROI and Social Security packages. L. Completes and processes routine releases of information to other VA and Federal Agencies and when requested, to patients and their families, insurance representatives, physicians, hospitals, and city and state health agencies according to VA directives. Processing must be accomplished within established time standards. Accurately enters all requests into the ROI software with necessary information for each request for health information. Completes necessary transactions for deposit of money collected from subpoenas, legal fees, and processing fees for release of information to individuals and insurance companies. GS-0675-06: A. The duties in this position are primarily advisory and technical in nature. Incumbent is responsible for evaluating the adequacy of each completed authorization form. Screens each request for information to determine urgency and assures that most urgent requests are completed fist using established priority systems. Personally greets veterans/visitors and assists them in determining the exact nature of the request and whether the information requested can be released. B. Applies public laws, rules, regulations and exclusions governing confidentiality of the medical record, including the Privacy Act, Freedom of Information Act and 38 U.S.C. 7332 governing the release of records containing information regarding the treatment of or referral for drug and/or alcohol abuse, Sickle Cell Anemia and infection with Human Immunodeficiency Virus (HIV).<h3>Education</h3>Experience/Education Combination. Equivalent combinations of creditable experience and education are qualifying towards meeting basic experience requirements. The following experience and 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 courses. (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 Armed Forces or the U.S. Maritime Service under close medical and professional supervision. The training program may be substituted on a month- 3 for-month basis for up to six months of experience provided the training program included courses in anatomy and physiology, and health record techniques and procedures. Grandfathering Provision. All persons employed in VHA as a MRT (ROI) 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. 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: (1) 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. (2) Employees who are 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. (3) 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 Grade Determinations: GS-0675-04: (1) Experience or Education. None beyond basic requirements. (2) Assignment. Employees at this level serve in entry level MRT (ROI) position and 4 receive close supervision and support from more experienced ROI staff members. MRTs (ROI) receive and validate authorization forms and requests for information, and prioritize requests per policies and regulations. They use various computer applications to track and release all authorized ROI requests. They process and release health information to authorized first- and third-party requestors. MRTs (ROI) initiate and maintain the accounting of disclosure for all records disclosed from a Privacy Act system of records. They ensure compliance with policies, procedures, laws, and regulations governing privacy and release of information. GS-0675-05: (1) Experience. One year of creditable experience equivalent to the next lower grade level; OR, (2) Education. Successful completion of 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 and physiology, legal aspects of health care, and introduction to health records). (3) Assignment. Employees at this grade level serve in developmental positions as MRTs (ROI) and receive guidance from more experienced staff members for complex release of information procedures. They receive and validate authorization forms and requests for information and prioritize requests according to policies and regulations. They utilize various computer applications to track and release all authorized release of information requests. They also process and release health information to authorized first- and third-party requestors. They initiate and maintain accounting of disclosure for all records disclosed from a Privacy Act system of records. They communicate with internal and external stakeholders to provide technical expertise regarding the release of information process. They ensure compliance with policies, procedures, laws, and regulations governing privacy and release of information. (4) Demonstrated Knowledge, Skills, and Abilities. In addition to the experience above, the candidate must demonstrate all of the following KSAs: (a) Ability to utilize health information technology and various office software products utilized in MRT (ROI) positions (e.g., the electronic health record, release of information systems, etc.). (b) Knowledge of health record documentation guidelines and processes for disclosing protected health information. (c) Ability to manage priorities and coordinate work in order to complete duties within required timeframes, and the ability to follow-up on pending issues. (d) Knowledge of policies, procedures, laws, and regulations governing privacy and release of information. 5 (e) Ability to communicate with individuals from various backgrounds to obtain the desired effect or gaining information by establishing rapport