Medical Records Tech (Hit)

Duties include but are not limited to:

• 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.
• Adheres to established documentation requirements as outlined by The Joint Commission regulations Veterans Health Administration (VHA) guidelines as well as medical-legal requirements.
• Assists clinicians with completion of delinquent/incomplete health records.
• Performs the quantitative and qualitative analysis on both computer and paper based health records.
• Consults with the appropriate clinician(s) for clarification when conflicting or ambiguous information appears in the health record documentation. Identifies health record deficiencies tracks deficiencies and ensures that the appropriate individual completes their deficiencies.
• Assists physicians with the completion of delinquent/incomplete health records and serves as the expert resource for clinical staff regarding requirements for complete documentation.
• 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.
• Tracks electronic signatures and documents deficiencies and communicates these deficiencies to clinical staff for correction. Notification can be in person internal e-mail telephone or through other normal routing system. Works independently resolving health record deficiency issues/erroneous documents and corrective action required within CPRS and only seeks guidance of immediate supervisor and/or Clinical Application Coordinator when issues surface when no precedent or procedure has been developed.

Work Schedule: Monday - Friday 8:00am to 4:30pm
Telework: Not Available
Virtual: This is not a virtual position.
Remote: This is not a remote position.
Functional Statement #: 000000
Relocation/Recruitment Incentives: Not Authorized
Permanent Change of Station (PCS): Not Authorized

• You must be a U.S. Citizen to apply for this job.
• All applicants tentatively selected for VA employment in a testing designated position are subject to urinalysis to screen for illegal drug use prior to appointment. Applicants who refuse to be tested will be denied employment with VA.
• 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.
• 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 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.

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 and Education:
  1. Experience. One year of creditable experience that indicates knowledge of medical terminology and 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 (ROI) work. OR
  2. 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 and 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 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-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.

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 GS-04: None beyond basic requirements

Grade Determination for GS-05:

(1) Experience: One year of experience equivalent to the next lower level. OR

(2) Education: A bachelors 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/Education requirement the candidate must demonstrate all of the following Knowledge Skills and Abilities:

(a) Ability to communicate effectively with internal and external customers.
(b) 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).
(c) Knowledge of health record documentation guidelines and industry standards.
(d) Ability to manage priorities and coordinate work to complete duties within required timeframes.
(e) Ability to apply knowledge of medical terminology and human anatomy to fully understand the content of a health record.

Grade Determination for GS-06:

1. Experience: One year of experience equivalent to the next lower grade level.

In addition to the Experience requirement the candidate must demonstrate all of the following Knowledge Skills and Abilities:

(a) Ability to navigate efficiently through the health record to locate needed information.
(b) Ability to analyze health record documentation to ensure compliance with guidelines and industry standards.
(c) Skill in investigating potential health record errors and making corrections when appropriate.
(d) Skill in interpreting and applying health information guidelines and using judgment to complete assignments.
(e) Ability to follow up on incomplete health record documentation.

Grade Determination for GS-07:


1. Experience: One year of experience equivalent to the next lower grade level.


In addition to the Experience requirement the candidate must demonstrate all of the following Knowledge Skills and Abilities:


(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 and 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 and 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 and utilize problem-solving techniques in the accomplishment of work.


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).


Reference: For more information on this qualification standard please visit 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: The work is for the most part sedentary with occasional lifting of files usually not exceeding 25 lbs.