Medical Records Technician (HIT)

Duties

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, and 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. They conduct the review of incomplete records for individuals clearing the facility. MRTs HIT coordinate the use of medical speech recognition/transcription and monitor, verify, troubleshoot, correct, and/or upload all transcription/medical speech recognition to maintain completeness and accuracy of health records. They serve as the technical expert in health record content and documentation requirements.

The Roseburg VA Healthcare System consists of one Veterans Health Administration (VHA) facility located in Roseburg, OR, and three outpatient clinics. RVAHCS also operates a community reintegration service center, consisting of a Homeless Program, Homeless Housing Program with the Department of Health and Human Services
(HUDN ASH), Substance Abuse and Vocational Rehabilitation services. Specialty services include Cardiology, Neurology, Infectious Diseases, Optometry, Ophthalmology, ENT, Endocrinology, Urology, Renal, Gerontology, Pulmonary, Gastroenterology, General Surgery, Dermatology and Vocational Rehabilitation.

Functions:
Incumbent serves as technical expert in health record content and documentation requirements. Incumbent is responsible for performing quantitative and qualitative reviews of health record documentation. Incumbent is responsible for ensuring that all patient care data entered in the Electronic Health Record (EHR) is accurate, timely, and completed. 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.

The incumbent performs the quantitative and qualitative analysis on both electronic 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. The incumbent 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.
Assesses the electronic and paper health record for completeness and notes deficiencies in the record deficiency monitoring system.

Work Schedule: Monday - Friday 0800-1630
Telework: Available, Pending supervisor approval
Virtual: This is not a virtual position.
Functional Statement #: 000000
Relocation/Recruitment Incentives: Not Authorized
Permanent Change of Station (PCS): Not Authorized
Financial Disclosure Report: Not required

Requirements

Conditions of Employment

• 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.
• 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.
Successfully pass the E-Verify employment verification check. To learn more about E-Verify, including your rights and responsibilities, visit e-verify.gov

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How You Will Be Evaluated

• Benefits

  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 windowLearn more about federal benefits.

  Review our benefits

  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.

• Required Documents

  As a new or existing federal employee, you and your family may have access to a range of benefits. Your benefits depend on the type of position you have - whether you're a permanent, part-time, temporary or an intermittent employee. You may be eligible for the following benefits, however, check with your agency to make sure you're eligible under their policies.

  To apply for this position, you must provide a complete Application Package which includes:
  

  • Resume

  
  
  The following documents are accepted, and may be required if applicable to your eligibility and/or qualifications for this position. Please use this checklist to ensure you have included all documents required for your application, such as a copy of your transcript (if using education to qualify), SF-50's (current/former Federal employees), etc.
  
  

  • Cover Letter
  • DD-214/ Statement of Service
  • Disability Letter (Schedule A)
  • Disability Letter (VA)
  • License
  • Other (1)
  • PCS Orders
  • Performance Appraisal
  • Professional Certification
  • Resume
  • Separation Notice (RIF)
  • SF-15
  • SF-50/ Notification of Personnel Action
  • Transcript

  
  
  Veterans' Preference: When applying for Federal Jobs, eligible Veterans should claim preference for 5pt (TP), 10pt (CP/CPS/XP), or for Sole Survivor Preference (SSP) in the questionnaire. You must provide a legible copy of your DD214(s) which shows dates and character of service (honorable, general, etc.). If you are currently serving on active duty and expect to be released or discharged within 120 days you must submit documentation related to your active duty service which reflects the dates of service, character of service (honorable, general, etc.), and dates of impending separation. Additionally, disabled veterans and others eligible for 10-point preference (such as widows or mothers of eligible Veterans) must also submit an SF-15 "Application for 10 Point Veteran Preference" with required proof as stated on the form. Documentation is required to award preference. For more information on Veterans' Preference, please visit Feds Hire Vets - Veterans - Job Seekers - Veterans' Preference.

  If you are relying on your education to meet qualification requirements:

  Education must be accredited by an accrediting institution recognized by the U.S. Department of Education in order for it to be credited towards qualifications. Therefore, provide only the attendance and/or degrees from schools accredited by accrediting institutions recognized by the U.S. Department of Education.

  Failure to provide all of the required information as stated in this vacancy announcement may result in an ineligible rating or may affect the overall rating.

• How to Apply

  All applicants are encouraged to apply online. To apply for this position, you must complete the full questionnaire and submit the documentation specified in the Required Documents section below. The complete application package must be submitted by 11:59 PM (ET) on 04/16/2024 to receive consideration. To preview the questionnaire click https://apply.usastaffing.gov/ViewQuestionnaire/12331815.

  • To begin, click Apply Online to create a USAJOBS account or log in to your existing account. Follow the prompts to select your USA JOBS resume and/or other supporting documents and complete the occupational questionnaire.

  • Click Submit My Answers to submit your application package.

  
  NOTE: It is your responsibility to ensure your responses and appropriate documentation is submitted prior to the closing date.
  
  To verify your application is complete, log into your USA JOBS account, https://my.usajobs.gov/Account/Login, select the Application Status link and then select the more information link for this position. The Details page will display the status of your application, the documentation received and processed, and any correspondence the agency has sent related to this application. Your uploaded documents may take several hours to clear the virus scan process. To return to an incomplete application, log into your USA JOBS account and click Update Application in the vacancy announcement. You must re-select your resume and/or other documents from your USA JOBS account or your application will be incomplete.

  Agency contact information

  Caleb Stone

  Phone

  208-422-1315

  Email

  CALEB.STONE@VA.GOV

  Address

  Roseburg VA Medical Center
  913 Northwest Garden Valley Boulevard
  Roseburg, OR 97471
  US

  Next steps

  Once your online application is submitted you will receive a confirmation notification by email. After we receive application packages (including all required documents) and the vacancy announcement closes, we will review applications to ensure qualification and eligibility requirements are met. After the review is complete, a referral certificate(s) is issued and applicants will be notified of their status by email. Referred applicants will be notified as such and may be contacted directly by the hiring office for an interview. All referred applicants receive a final notification once a selection decision has been made.
  
  You may check the status of your application at any time by logging into your USA Jobs account and clicking on Applications. Information regarding your application status can be found in the USAJobs Help Center.
  
  NOTE: Participation in the seasonal influenza program is a condition of employment and a requirement for all Department of Veterans Affairs Health Care Personnel (HCP). It is a requirement that all HCP to receive annual seasonal influenza vaccination or obtain an exemption for medical or religious reasons. Wearing a face mask is required when an exemption to the influenza vaccination has been granted. HCP in violation of this directive may face disciplinary action up to and including removal from federal service. HCP are individuals who, during the influenza season, work in VHA locations or who come into contact with VA patients or other HCP as part of their duties. VHA locations include, but are not limited to, VA hospitals and associated clinics, community living centers (CLCs), community-based outpatient clinics (CBOCs), domiciliary units, Vet centers and VA-leased medical facilities. HCP include all VA licensed and unlicensed, clinical and administrative, remote and onsite, paid and without compensation, full- and part-time employees, intermittent employees, fee basis employees, VA contractors, researchers, volunteers and health professions trainees (HPTs) who are expected to perform any or all of their work at these facilities. HPTs may be paid or unpaid and include residents, interns, fellows and students. HCP also includes VHA personnel providing home-based care to Veterans and drivers and other personnel whose duties put them in contact with patients outside VA medical facilities.

• Fair and Transparent

  The Federal hiring process is set up to be fair and transparent. Please read the following guidance.

  • Equal Employment Opportunity (EEO) Policy
  • Reasonable accommodation policy
  • Financial suitability
  • Selective Service
  • New employee probationary period
  • Signature and false statements
  • Privacy Act
  • Social security number request

Required Documents

Clarification from the agency

Applicants will be referred in the following order: First - Current Permanent VA Roseburg Healthcare System Employees; Second - Current Permanent VA Employees Nationwide; Third - Current Permanent Federal Employees Other Agencies; Fourth - Former Permanent Federal Employees; Fifth - U.S. Citizens