Medical Records Technician (HIT)

Summary

This position is located in the Health Information Management (HIM) section of the Patient Business Service at the Chalmers P. Wylie VA ACC. Medical Record Technicians (MRT) Health Information Technician (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.

Learn more about this agency

Duties

Help

Duties include, but are not limited, to the following:

• Performs quarterly quantitative audits of medical records to evaluate problems and potential problems.
• Ensures compliance with The Joint Commission standards, VA regulations and directives and standards of practice pertaining to documentation (timeliness, accuracy, completeness).
• Prepares narrative and graphic information (as requested) of data analyzed for the Chief HIMS/Supervisory Medical Records Administrative Specialist.
• Determines the cause of inadequacies/errors and suggests corrective measures- reports include indicators for medical record timeliness, consults, registry exams.
• Serves as the point of contact for Dragon Medical Software.
• Provides technical assistance and advice to administrative, medical and professional staff and support staff regarding documentation guidelines, consults, Special Environmental Health Registry exams, Dragon Medical Software, and other HIMS functions as needed.
• Acts as facility decedent affairs to promptly respond to requests from coroner offices regarding the need for completion of death certificates and medical record information for autopsies.
• Researches ways to retrieve a death certificate if not provided by the funeral home or family of the deceased Veteran.
• Reviews, analyzes, abstracts, compiles, maintains, and/or extracts health data to perform duties within the scope of duties such as organizing medical records, checking for completeness, accuracy and compliance, and/or scanning, privacy, research, education, revenue, or similar functions.

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

Telework : Ad-hoc as determined by the agency policy.

Virtual: This is not a virtual position.

Functional Statement # : 917150/917160/917170/915650

Relocation/Recruitment Incentives : Not Authorized

Permanent Change of Station (PCS): Not Authorized

Requirements

Help

Conditions of employment

• You must be a U.S. Citizen to apply for this job.
• 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, driver's licenses or state-issued identification 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 interest. In 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.

Qualifications

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

• 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.

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).

• English Language Proficiency. MRTs HIT must be proficient in spoken and written English, as required by 38 U.S.C. § 7403(f).

Grade Determinations And Assignments.

Medical Records Technician (HIT), GS-4 (Entry Level)

• Experience or Education. None beyond basic requirements.

Medical Records Technician (HIT), GS-5 (Developmental Level 1)

• Experience. One year of experience equivalent to the next lower level. OR,
• Education. A bachelor'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 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).

Demonstrated Knowledge, Skills, and Abilities. In addition to the experience above, the candidate must demonstrate all of the following KSAs:

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

Medical Records Technician (HIT), GS-6

• 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 all of the following KSAs:

• Ability to navigate efficiently through the health record to locate needed information.
• Ability to analyze health record documentation to ensure compliance with guidelines and industry standards.
• Skill in investigating potential health record errors and making corrections, when appropriate.
• Skill in interpreting and applying health information guidelines and using judgement to complete assignments.
• Ability to follow up on incomplete health record documentation.

Medical Records Technician (HIT), GS-7 (Full Performance Level)

• 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 all of the following KSAs:

• 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.
• Ability to take appropriate actions if health record content is not adequate, accurate, timely, and/or reliable.
• Ability to communicate both orally and in writing with individuals or groups, to facilitate compliance with established policies and regulations.
• Skill in using appropriate software and computer applications to analyze and record documentation trends.
• Ability to apply qualitative and/or quantitative methods for assessment and improvement of health records.
• Ability to work independently and utilize problem-solving techniques in the accomplishment of work.

Reference: For more information on this qualification standard, please visit

The full performance level of this vacancy is GS-7. The actual grade at which an applicant may be selected for this vacancy is in the range of GS-4 to GS-7.

Physical Requirements: A good portion of the work is sedentary but may require some walking, standing, bending, lifting, pulling, stretching and occasional lifting of boxes of records or documents. Work most often is performed in an office setting but may be performed throughout the facility in other settings. Incumbent must be safety conscious at all times.

Education

Note: Only education or degrees recognized by the U.S. Department of Education from accredited colleges, universities, schools, or institutions may be used to qualify for Federal employment. You can verify your education here: If you are using foreign education to meet qualification requirements, you must send a Certificate of Foreign Equivalency with your transcript in order to receive credit for that education. For further information, visit:

Additional information

Receiving Service Credit for Earning Annual (Vacation) Leave: Federal Employees earn annual leave at a rate (4, 6 or 8 hours per pay period) which is based on the number of years they have served as a Federal employee. Selected applicants may qualify for credit toward annual leave accrual, based on prior work experience or military service experience. This credited service can be used in determining the rate at which they earn annual leave. Such credit must be requested and approved prior to the appointment date and is not guaranteed.

During the application process you may have an option to opt-in to make your resume available to hiring managers in the agency who have similar positions. Opting in does not impact your application for this announcement, nor does it guarantee further consideration for additional positions.

This job opportunity announcement may be used to fill additional vacancies.

This position is in the Excepted Service and does not confer competitive status.

VA encourages persons with disabilities to apply. The health-related positions in VA are covered by Title 38, and are not covered by the Schedule A excepted appointment authority.

If you are unable to apply online or need an alternate method to submit documents, please reach out to the Agency Contact listed in this Job Opportunity Announcement.

Under the Fair Chance to Compete Act, the Department of Veterans Affairs prohibits requesting an applicant's criminal history prior to accepting a tentative job offer. For more information about the Act and the complaint process, visit Human Resources and Administration/Operations, Security, and Preparedness (HRA/OSP) at The Fair Chance Act.

Candidates should be committed to improving the efficiency of the Federal government, passionate about the ideals of our American republic, and committed to upholding the rule of law and the United States Constitution.

Help

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.