Medical Records Technician (Health Information Technician)

Total Rewards of a Allied Health Professional

Position involves technical work concerned with processing and maintenance of medical records. Work requires practical knowledge of human anatomy physiology medical terminology and legal requirements of the medical record. Analytical ability judgement discretion and a high level of tact and negotiating are required on a daily basis to carry out functions of this position.

Functions

• Responsible for
  • Providing administrative support for the Medical Center Health Information Program
  • Abstraction of clinical information for ongoing regulatory reviews
  • Applying practical knowledge of laws and regulations of HIM
• Apply knowledge of medical terminology human anatomy/physiology and disease processes. Navigate efficiently through the electronic medical record.
• Understands internal organization of medical records and medical record references.
• Abstracts clinical information for ongoing regulatory medical record reviews. Validates data collected creates status reports and provides prepared data to HIMS management.
• Coordinates review activities with the Quality Improvement Program to satisfy external accreditation requirements and performance measures.
• Reads and abstracts medical information. Assure information being reviewed is accurate. Works with the HIM team to identify medical record review trends and documentation discrepancies.
• Reviews abstracted information. Will be used for medical record completion.
• Tracks incomplete reports for completion using various systems. Upload clinical reports.
• Prepares Medical Record Review Data Reports Statistics and Quality Reviews that show current trends. The Medical Record Review Data will be presented and explained to the Assistant Chief and Chief of Health Information monthly.
• Reviews analyzes and reports HIM performance monitors for coding and other medical record review topics.
• Reviews documentation corrections to ensure coded data reflects any change in documentation; makes coding changes as appropriate.
• Performs audits and analyses preparing and presenting findings and recommendations.
• Provides professional consultation management assistance and health record support.
• Tracks electronic signatures and documents deficiencies and communicates these deficiencies to clinical staff for correction. Works independently resolving health record deficiency issues/erroneous documents and corrective action required.
• Prepares complex reports noting the status of all incomplete/delinquent records and compliance reports.
• Preforms analytical tasks associated with the resolution of filing errors on reports uploaded by a transcription vendor.
• Identifies reviews verifies and corrects all statistical data concerning medical transcription. Compares and resolves discrepancies.
• Reviews health records for adherence with guidelines.
• Works with interdisciplinary staff.
• Develops and compiles written reports trending provider specific service and hospital compliance reports regarding admission subsequent and discharge notes. Obtains statistical information applies statistical formulas and completes statistical reports for medical center management.

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.
• 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 ( Effective May 7 2025 drivers 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 physical evaluation.
• 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.

• 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.

Qualifications

NOTE: THE 2-PAGE RESUME REQUIREMENT DOES NOT APPLY TO THIS OCCUPATIONAL SERIES. FOR MORE INFORMATION REFER TO REQUIRED DOCUMENTS BELOW

To qualify for this position applicants must meet all requirements within 30 days of the closing date of this announcement.

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
  • 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
  • Education: An associates 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
  • 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:
    • 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.
    • 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.

1. Ability to communicate effectively with internal and external customers.
2. 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).
3. Knowledge of health record documentation guidelines and industry standards.
4. Ability to manage priorities and coordinate work to complete duties within required timeframes.
5. Ability to apply knowledge of medical terminology and human anatomy to fully understand the content of a health record.

1. Ability to navigate efficiently through the health record to locate needed information.
2. Ability to analyze health record documentation to ensure compliance with guidelines and industry standards.
3. Skill in investigating potential health record errors and making corrections when appropriate.
4. Skill in interpreting and applying health information guidelines and using judgment to complete assignments.
5. Ability to follow up on incomplete health record documentation.

1. 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.
2. Ability to take appropriate actions if health record content is not adequate accurate timely and/or reliable.
3. Ability to communicate both orally and in writing with individuals or groups to facilitate compliance with established policies and regulations.
4. Skill in using appropriate software and computer applications to analyze and record documentation trends.
5. Ability to apply qualitative and/or quantitative methods for assessment and improvement of health records.
6. Ability to work independently and utilize problem-solving techniques in the accomplishment of work.