Lead Medical Records Technician (HIT)

This position is located in the Health Information Management (HIM) section at the John D Dingell VA Medical Center. MRTs HIT perform incomplete health record analysis. They review, analyze, abstract, maintain, extract, and compile information from the health record. MRTs HIT check for accuracy, completeness, and timeliness of the health record and monitor and report for regulatory compliance.

Major duties and responsibilities include but are not limited to the following: Serve as technical expert in health record content and documentation requirements. Responsible for performing quantitative and qualitative reviews of health record documentation. Responsible for ensuring that all patient care data entered in Electronic Health Record (EHR) is accurate, timely, and completed. Adhere to established documentation requirements as outlined by The Joint Commission regulations, Veterans Health Administration (VHA) guidelines, as well as medical-legal requirements.

Review records for adherence with CMS guidelines related to student, resident supervision and attending physician presence and documentation. Compile reports to ensure provider specific and service compliance. Maintain 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. Workload Report and contract transcription logs as it relates to timeliness and accuracy of dictated reports completed by medical transcription contractor (as applicable).

Review health records for adherence with guidelines related to resident supervision and attending physician presence. Prepare weekly and monthly reports noting the status of all incomplete/delinquent health records and submits the reports to the appropriate administrative and clinical staff. Participate in routine and focused reviews for the purpose of identifying problems and potential problems in health record documentation as part of the health record review process.

Identify and abstract information from health records for special studies and audits both internal and external. Lead Duties: Facilitates team or unit processes by working in collaboration with team members or employees to ensure that tasks are completed, that good working relationships among team members and with management are maintained, and that team priorities and goals, needs, and achievements are coordinated with management.

Performs lead functions over MRT (HIT) positions. Provides guidance and technical direction necessary for accomplishing the work of the unit or team. Serves as work leader, assuring the work assignments of employees in the unit are carried out. Distributes and balances workload and tasks among employees. Assures the timely accomplishment of work assigned to the team. Assures each team member has an integral role in developing the final product or providing the assigned service.

Communicates to the team the problem to be solved or program issues under review and coaches the team and/or individual team members in identifying the parameters of a viable solution. Ensures the organization's "vision" is integrated into the team's goals, strategies, activity plans, and work products. Ensures team members participate in both short-term and long-term planning stages of team projects. Continually interacts with team members aimed at building consensus and to serve as negotiator and coach for coordination of team initiatives.

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. Work Schedule: Monday- Friday; 08:00am- 04:30pm. Schedule may be subject to change based on the needs of the Agency. Recruitment/Relocation Incentives (Sign-on Bonus): Not Authorized Permanent Change of Station (Relocation Assistance): Not Authorized Pay: Competitive salary and regular salary increases When setting pay, a higher step rate of the appropriate grade may be determined after consideration of higher or unique qualifications or special needs of the VA (Above Minimum Rate of the Grade).

Paid Time Off: 37-50 days of annual paid time offer per year (13-26 days of annual leave, 13 days of sick leave, 11 paid Federal holidays per year) 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) Telework: Not Available Virtual: This is not a virtual position.

Functional Statement #:916080 Permanent Change of Station (PCS): Not authorized

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: Citizenship. Citizen of the United States.(Non-citizens may be appointed when it is not possible to recruit qualified citizens in accordance with chapter 3, section A, paragraph 3g, this part.) 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 associate'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 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.

English Language Proficiency: MRTs HIT must be proficient in spoken and written English, as required by 38 U.S.C. § 7403(f). 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). Grandfathering Provision. All persons employed in VHA as a MRT HIT, on the effective date of this qualification standard, are considered to have met all qualification requirements for the grade held, including positive education and licensure/certification/ registration that are part of the basic requirements of the occupation.

For employees who do not meet all the basic requirements in this standard, but who met the qualifications applicable to the position at the time they were appointed to it, the following provisions apply: (1) Such employees in an occupation that does not require a licensure/certification/ registration, may be reassigned, promoted, or demoted within the occupation, but will not be promoted beyond the journey level or placed in supervisory or managerial positions.

(2) Employees appointed on a temporary basis prior to the effective date of the qualification standard may not have their temporary appointment extended, or be reappointed on a temporary or permanent basis, until they fully meet the basic requirements of the standard. (3) Employees initially grandfathered into this occupation, who subsequently obtain additional education and/or licensure/certification/registration that meet all the basic requirements of this qualification standard, must maintain the required credentials, as a condition of employment in the occupation.

Experience. Creditable Experience. Experience is only creditable if it is paid or non-paid employment directly related to the position to be filled, or in a related field, such as medical support assistants, clinic/ward clerks, health record file room/scanning technicians, medical coding, or other positions that include knowledge of the content and uses of health records. To be creditable, the candidate's experience must have demonstrated the use of knowledge, skills, and abilities associated with current MRT HIT practice.

Part-Time Experience. Part-time experience as a MRT HIT is creditable according to its relationship to the full-time workweek. For example, a MRT HIT would receive one week of full-time credit for each two weeks of half-time work. Quality of Experience. To be creditable, experience must be documented on the application or resume and verified in an employment reference, or through other independent means. Grade Determinations.

In addition to the basic requirements for employment, candidates must meet the following grade-determining criteria for placement: Lead Medical Records Technician (HIT), GS-08. Experience. One year of experience equivalent to the next lower grade level. Demonstrated Knowledge, Skills, and Abilities. In addition to the experience above, the candidate must demonstrate the following KSAs: Comprehensive knowledge of health record technology methods, procedures, and techniques.

Ability to work with a team to provide technical guidance, and to plan, organize, and coordinate activities to effectively complete job assignments (i.e., distributing workload, monitoring the status and progress of work, monitoring accuracy of work, and ensuring required timelines are met.) Skill in informatics, laboratory data flow, and laboratory processes. Skill in communicating effectively, both orally and in writing, to meet program objectives.

Ability to prepare reports in a variety of formats and present data to individuals at various organizational levels. Ability to coordinate and provide staff development and training. Reference: For more information on this qualification standard, please visit https://www.va.gov/ohrm/QualificationStandards/. The full performance level of this vacancy is GS-08. Physical Requirements: Light Lifting under 15 pounds; reaching above shoulder; use of fingers' both hands required; walking .5 hours per day; standing .5 hours per day; specific visual requirements - 20/20 vision required for both eyes; both eyes required; depth perception; ability to distinguish basic colors; ability to distinguish shades of colors; hearing ( aid permitted).

Environmental Factors - dust, working closely with others and working alone. See VA Directive and Handbook 5019.