Medical Records Technician (HIT)

Job Title

Major duties include but are not limited to:

• 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 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. Assists clinicians with completion of delinquent/incomplete health records.
• The incumbent performs the quantitative and qualitative analysis on both computer 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 paper health record and electronic Computerized Patient Record System(CPRS) for completeness and notes deficiencies in the Medical Records Committee.
• Identifies reviews, verifies, and corrects all statistical data concerning medical transcription to maintain accuracy of medical and statistical reports. Compares and resolves discrepancies between daily Gains and Losses Sheet, Digital System Workload Report and contract transcription logs as it relates to timeliness and accuracy of dictated reports completed by medical transcription contractor.
• Reviews health records for adherence with guidelines related to resident supervision and attending physician presence.
• Works with interdisciplinary staff to solve problems regarding proper health record documentation and completion.
• Develops and compiles written reports trending provider specific, service, and hospital compliance reports regarding admission subsequent and discharge notes. Obtains statistical information, applies statistical formulas, and completes statistical reports for medical center management.
• Prepares weekly and monthly reports noting the status of all incomplete/delinquent health records and submits the reports to the appropriate administrative and clinical staff. Participates in routine and focused reviews for the purpose of identifying problems and potential problems in record documentation as part of the health record review process. Identifies and abstracts information from health records for special studies and audits both internal and external.

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

Telework: Not Available

Virtual: This is not a virtual position.

Functional Statement #: 58477-A/ 58478-A/ 58479-A/ 58480-A

Relocation/Recruitment Incentives: Not Authorized

Permanent Change of Station (PCS): Not Authorized