Medical Records Technician (Health Information Technician)

Department of Veterans Affairs

CRITICAL Shortage LIST OIG: 38 U.S.C. 7412 waives the requirement to apply Veterans' preference to external applicants for appointments made during the fiscal year to hybrid title 38 occupations among those reported to have the largest staffing shortages. This position is located in the Health Information Management (HIM) section at the VA Maryland Healthcare Center. Medical Records Technician (Health Information Technician) perform incomplete health record analysis.

• GS 4 - ENTRY LEVEL Responsible for abstraction of clinical information for ongoing regulatory reviews and deficiency analysis. Contacts physicians and other ancillary service personnel regarding dictation and/or signatures. Communicates very closely with the clinical staff to answer questions and resolve problems to ensure quality documentation in the health records. Utilizes basic knowledge of medical terminology, anatomy and physiology, and coding to research and collect information for various medical studies and research projects. Monitors house staff rotation schedule and contacts resident house staff to ensure completion of health records prior to departure from the Medical Center. Coordinates review activities with the Quality Improvement Program to satisfy external accreditation requirements, and to satisfy current Medical Center performance measures. GS 5 - DEVELOPMENTAL LEVEL 1 Responsible for abstraction of clinical information for ongoing regulatory reviews and deficiency analysis. Assists clinical staff by providing information regarding required documentation. 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. Performs analytical tasks associated with the resolution of "filing" errors on reports uploaded by a transcription vendor. Notifies appropriate physician and other personnel of the status of dictation. Collects data from data validation activities and audits that support continuity of patient care, budget/resource allocation, performance measurement, quality management, research, VA comparative analysis and benchmarking. GS 6 - DEVELOPMENTAL LEVEL 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. Responsible for ensuring 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 to ensure that all records contain sufficient information to meet medico-legal requirements, to ensure continuity of patient care, and to support education and research needs. Assists clinicians with completion of delinquent / incomplete health records. GS 7 - FULL PREFORMANCE LEVEL 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. Responsible for ensuring 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. Notifies clinicians of missing, incomplete, or inaccurate information in their signature blocks (e.g., missing or inaccurate credentials). Selected applicants may qualify for credit toward annual leave accrual, based on prior [work experience] or military service experience. Parental Leave: After 12 months of employment, up to 12 weeks of paid parental leave in connection with the birth, adoption, or foster care placement of a child. Child Care Subsidy: After 60 days of employment, full time employees with a total family income below $144,000 may be eligible for a childcare subsidy up to 25% of total eligible childcare costs for eligible children up to the monthly maximum of $416.66. Retirement: Traditional federal pension (5 years vesting) and federal 401K with up to 5% in contributions by VA Insurance: Federal health/vision/dental/term life/long-term care (many federal insurance programs can be carried into retirement) Work Schedule: Monday - Friday 8:00 am -4:30 pm Telework: Available Virtual: This is not a virtual position. Functional Statement #: 000000 / 000000 / 260368-F / 260283-F Relocation/Recruitment Incentives: Not Available Permanent Change of Station (PCS): Not Authorized

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