Medical Records Technician (HIT)

Job Title

Job duties include but are not limited to:

• Serves as technical expert in health record content and documentation requirements.
• Responsible for performing quantitative and qualitative reviews of health record documentation.
• Ensures that all patient care data entered in VistA and/or Computerized Patient Record System (CPRS) 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.
• Assesses the paper health record and electronic Computerized Patient Record System (CPRS) for completeness and notes deficiencies in the Record Review Assistant (RRA) software program on the Citrix platform.
• Tracks electronic signatures and documents deficiencies and communicates these deficiencies to clinical staff for correction.

Work Schedule: Monday- Friday 8:00am - 4:30pm

Telework: Not Available

Virtual: This is not a virtual position.

Relocation/Recruitment Incentives: Not Authorized

Permanent Change of Station (PCS): Not Authorized