Medical Records Technician (HIT)
US Department of Veterans Affairs
Medical Records Technician
The Medical Records Technician (MRT) Health Information Technician (HIT) serves as technical expert in health record content, documentation requirements and is responsible for performing quantitative and qualitative reviews of health record documentation. The MRT is responsible for ensuring that all patient care data entered in VistA and/or Computerized Patient Record System (CPRS) is accurate, timely, and completed. The MRT adheres to established documentation requirements as outlined by The Joint Commission regulations, Veterans Health Administration (VHA) guidelines, as well as medical-legal requirements. Duties and responsibilities include but are not limited to the following:
- 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.
- Identifies health record deficiencies, tracks deficiencies and ensures that the appropriate individual completes their deficiencies.
- Assists physicians with the completion of delinquent/incomplete health records and serves as the expert resource for clinical staff regarding requirements for complete documentation.
- Expedites 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.
Work Schedule: TBD
Telework: Not eligible
Virtual: This is not a virtual position.
Functional Statement #: 10528-F, 10529-F, 10530-F, 09082A
Relocation/Recruitment Incentives: Not Authorized
Permanent Change of Station (PCS): Not Authorized
Financial Disclosure Report: Not required
US Department of Veterans AffairsVacancy posted 4 days ago
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