Medical Records Technician (HIT)

<p>This position is located in the Health Information Management (HIM) section of the Business Office at the Bay Pines VA Healthcare System (BPVAHCS). Medical Record Technician (MRTs) Health Information Technician (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.</p><h3>Major Duties</h3><p>Total Rewards of a Allied Health Professional Medical Records Technician (Health Information Technician) 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. Medical Record Technician duties and responsibilities include but are not limited to: Serves as technical expert in health record content and documentation requirements. Responsible for performing 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. 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. 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. Performs 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 to and filing/assigning it correctly. Identifies any blanks in transcribed documentation and takes appropriate action to track deficiencies, when required by local workflows, and follows up with the responsible provider for correction. Identifies reviews, verifies, and corrects all statistical data concerning medical transcription to maintain accuracy of medical and statistical reports. Compares and resolves discrepancies between reports of admission, discharge, transfers and all outpatient and ambulatory services with contract transcription logs as it relates to timeliness and accuracy of dictated reports completed by medical transcription contractor. Work Schedule: Monday through Friday from 8:00am to 4:30pm Recruitment Incentive (Sign-on Bonus): Not authorized Permanent Change of Station (Relocation Assistance): Not authorized Telework: Not eligible for telework. Virtual: This is not a virtual position. Functional Statement #: 32056F Permanent Change of Station (PCS): Not authorized PCS Appraised Value Offer (AVO): Not authorized</p><h3>Requirements</h3>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. 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 identification cards that are not REAL ID compliant cannot be utilized as an acceptable form of identification for employment. Must pass pre-employment physical examination. Participation in the seasonal influenza vaccination program is a requirement for all Department of Veterans Affairs Health Care Personnel (HCP). Complete all application requirements detailed in the "Required Documents" section of this announcement. As a condition of employment for accepting this position, you will be required to serve a 1 or 2-year trial period during which we will evaluate your fitness and whether your continued employment advances the public interest. In determining if your employment advances the public interest, we may consider: your performance and conduct; the needs and interests of the agency; whether your continued employment would advance organizational goals of the agency or the Government; and whether your continued employment would advance the efficiency of the Federal service. Upon completion of your trial period, your employment will be terminated unless you receive certification, in writing, that your continued employment advances the public interest.<h3>Education</h3>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/.