Medical Records Technician (HIT)

Health Record Specialist

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.
• Tracks electronic signatures and documents deficiencies and communicates these deficiencies to clinical staff for correction. Notification can be in person, internal e-mail, telephone, or through other normal routing system. Works independently resolving health record deficiency issues/erroneous documents and corrective action required within CPRS and only seeks guidance of immediate supervisor and/or Clinical Application Coordinator when issues surface when no precedent or procedure has been developed.
• Prepares complex weekly and monthly reports noting the status of all incomplete/delinquent records and compliance reports and submits the reports to the appropriate administrative and clinical staff.
• Conduct reviews of incomplete records for individuals clearing the facility. They create and monitor reports to ensure that deficiencies are resolved and completed appropriately
• Serve as the technical experts in health record content and documentation requirements.

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

Telework: ADHOC may be available.

This is not a virtual position.

Functional Statement #: F06066, F06067, F06068, F06069

Relocation/Recruitment Incentives: Not Authorized

Permanent Change of Station (PCS): Not Authorized.

Physical Requirements: See VA Directive and Handbook 5019, Employee Occupational Health Service.

• Due to a critical staffing shortage, 38 U.S.C. § 7412 waives the requirement to apply Veterans' preference for this job announcement.
• This position is not a Bargaining Unit position.
• Current and former Federal employees may submit copies of their most recent SF-50, (Notice of Personnel Action). The SF-50 must identify the position title, series, grade, step, tenure and type of service (competitive or Excepted). In some cases, more than one SF-50 may be required to show a higher grade previously held. Do not submit an award SF-50.
• This position is covered by locality-based comparability pay.
• Applicants may be referred over for consideration prior to the close date of this announcement.
• Narrative responses to the knowledge, skills and abilities (KSAs) may be required from the selectee in order to proceed with the appointment.