Medical Records Technician (Health Information Technician)

Summary

The Wilmington VA Medical Center is recruiting for a Medical Records Technician

• Health Information Technician (HIT). The Medical Records Technician

• Health Information Technician will function in Health Administration Service.

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Overview

• Accepting applications

• Open & closing dates

04/24/2024 to 05/06/2024

• Salary

$38,925 - $70,133 per year

• Pay scale & grade

GS 4 - 7

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Location

1 vacancy in the following location:

• Wilmington, DE 1 vacancy

• Remote job

No

• Telework eligible

No

• Travel Required

Not required

• Relocation expenses reimbursed

No

• Appointment type

Permanent -

• Work schedule

Full-time -

• Service

Excepted

• Promotion potential

7

• Job family (Series)

0675 Medical Records Technician

• Supervisory status

No

• Security clearance

Not Required

• Drug test

No

• Position sensitivity and risk

Non-sensitive (NS)/Low Risk

• Trust determination process

Suitability/Fitness

• Announcement number

CBSZ-12388928-24-BMB

• Control number

788268700

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This job is open to

• Federal employees

• Excepted service

Current excepted service federal employees.

• Internal to an agency

Current federal employees of this agency.

Clarification from the agency

Current, permanent Wilmington VA Medical Center Employees and Current, permanent Department of Veterans Affairs Employees.

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Duties

Duties of a Medical Records (HIT) Technician includes, but not limited to:

• 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.

• Consults with the appropriate clinician(s) for clarification when conflicting or ambiguous information appears in the health record documentation.

Work Schedule: Monday

• Friday, 8:00 a.m. to 4:30 p.m.

Compressed/Flexible:Available.

Telework: Not Available.

Virtual: This is not a virtual position.

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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 probationary period.

• Subject to background/security investigation.

• Selected applicants will be required to complete an online onboarding process.

• 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).

• Participation in the Coronavirus Disease 2019 (COVID-19) vaccination program is a requirement for all Veterans Health Administration Health Care Personnel (HCP) - See "Additional Information" below for details.

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.

• Experience: One year of experience equivalent to the next lower level. This is a developmental level for MRT HIT. 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 & compiles information from the health record, working under the review of the supervisor. They analyze health records for accuracy, completeness, timeliness, consistency, & 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 & monitor reports to ensure that deficiencies are resolved & completed appropriately. 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, & introduction to health records).

Grade Determinations:

GS-4

(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, & 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 & medical center performance measures. =

GS-5

(1) Experience

• One year of experience equivalent to the next lower level.

OR,

(2) 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).

Demonstrated Knowledge, Skills, and Abilities. In addition to the experience above, the candidate must demonstrate all of the following KSAs:

• Ability to communicate effectively with internal & external customers.

• Ability to utilize health information technology & various office software products used in health information management positions (e.g., Microsoft Excel, electronic health records, & delinquency tracking software).

• Knowledge of health record documentation guidelines and industry standards.

• Ability to manage priorities & coordinate work to complete duties within required timeframes.

• Ability to apply knowledge of medical terminology & human anatomy to fully understand the content of a health record.

GS-6

(1) Experience

• One year of experience equivalent to the next lower grade level.

(2) Assignment

• This is a developmental level for MRT HIT. 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.

Demonstrated Knowledge, Skills, and Abilities. In addition to the experience above, the candidate must demonstrate all of the following KSAs:

• Ability to navigate efficiently through the health record to locate needed information.

• Ability to analyze health record documentation to ensure compliance with guidelines & industry standards.

• Skill in investigating potential health record errors and making corrections, when appropriate.

• Skill in interpreting and applying health information guidelines & using judgment to complete assignments.

• Ability to follow up on incomplete health record documentation.

GS-7

(1) Experience

• One year of experience equivalent to the next lower grade level.

(2) Assignment

• 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, & 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.

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, & 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 & 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 & utilize problem-solving techniques in the accomplishment of work.

References: VA Handbook 5005/124 Part II Appendix G59

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.

Education

Physical Requirements: This position is primarily sedentary. Work includes walking, sitting/standing at desk, bending, keyboarding and use of mouse, and carrying light items.

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: https://sites.ed.gov/international/recognition-of-foreign-qualifications/.

Additional information

Receiving Service Credit or Earning Annual (Vacation) Leave: Federal Employees earn annual leave at a rate (4, 6 or 8 hours per pay period) which is based on the number of years they have served as a Federal employee. Selected applicants may qualify for credit toward annual leave accrual, based on prior work experience or military service experience. This credited service can be used in determining the rate at which they earn annual leave. Such credit must be requested and approved prior to the appointment date and is not guaranteed.

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.

Pursuant to VHA Directive 1193.01, VHA health care personnel (HCP) are required to be fully vaccinated against COVID-19 subject to such accommodations as required by law (i.e., medical, religious or pregnancy). VHA HCPs do not include remote workers who only infrequently enter VHA locations. If selected, you will be required to be fully vaccinated against COVID-19 and submit documentation of proof of vaccination before your start date. The agency will provide additional information regarding what information or documentation will be needed and how you can request a legally required accommodation from this requirement using the reasonable accommodation process.

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.

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• Benefits

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A career with the U.S. government provides employees with a comprehensive benefits package. As a federal employee, you and your family will have access to a range of benefits that are designed to make your federal career very rewarding. Opens in a new window

Learn more about federal benefits.

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Eligibility for benefits depends on the type of position you hold and whether your position is full-time, part-time or intermittent. Contact the hiring agency for more information on the specific benefits offered.

How You Will Be Evaluated

You will be evaluated for this job based on how well you meet the qualifications above.

IN DESCRIBING YOUR EXPERIENCE, PLEASE BE CLEAR AND SPECIFIC. WE MAY NOT MAKE ASSUMPTIONS REGARDING YOUR EXPERIENCE. Your application, resume, C.V., and/or supporting documentation will be verified. Please follow all instructions carefully. Errors or omissions may affect consideration for employment.

Experience refers to paid and unpaid experience, including volunteer work done through National Service programs (e.g., Peace Corps, AmeriCorps) and other organizations (e.g., professional; philanthropic; religions; spiritual; community; student; social). Volunteer work helps build critical competencies, knowledge, and skills and can provide valuable training and experience that translates directly to paid employment. You will receive credit for all qualifying experience, including volunteer experience.

The Department of Veterans Affairs performs pre-employment reference checks as an assessment method used in the hiring process to verify information provided by a candidate (e.g., on resume or during interview or hiring process); gain additional knowledge regarding a candidate's abilities; and assist a hiring manager with making a final selection for a position.

It is the policy of the VA to not deny employment to those that have faced financial hardships or periods of unemployment.

Veterans and Transitioning Service Members: Please visit the VA for Vets site for career-search tools for Veterans seeking employment at VA, career development services for our existing Veterans, and coaching and reintegration support for military service members.