Medical Records Technician (HIT)

This position is in the Health Information Management (HIM) section at the John D Dingell VA Medical Center. Medical Records Technician (Health Information Technician) 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. Total Rewards of a Allied Health Professional Major duties include: * Review health records to ensure all records contain enough information to meet medical/legal requirements, to ensure continuity of patient care, and to support education and research needs. * Analysis of PTF procedures track and monitor PTF errors and transmit corrected data timely. Set work priorities and meet deadlines for closing PTF records, preparing delinquent records, preparing excel spreadsheet and completing incomplete reports. 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. * Identifies PTF deficiencies, tracks deficiencies and ensures that the appropriate individual completes their deficiencies. The incumbent sends physicians with the incomplete/delinquent health records and serves as the expert resource for clinical staff regarding requirements for complete documentation. * Assesses the paper health record and electronic Computerized Patient Record System (CPRS) for completeness and notes deficiencies in the (IRT, Nuance, VISTA, VISTA Imaging). * Tracks 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 record deficiency issues/erroneous documents and corrective action required within CPRS and seeks guidance of immediate supervisor and/or Clinical Application Coordinator when issues surface when no precedent or procedure has been developed. Review and validate the Edit Analysis Lists (EALs) and the Dispositions in the PTF Master File (419). The EALs are sent in a VistA Mailman message in response to PTF or census transmissions that have data errors. The 419 and census reports are based in Austin at the AITC and require special access. * Prepares complex weekly and monthly reports noting the status of all incomplete/delinquent records and compliance reports and submits the reports to the Chief of HIMS, BP Leadership and clinical staff. * Performs analytical tasks associated with the resolution of "filing" errors on reports uploaded onto spreadsheet. This includes correctly identifying the coder on the report and providing this information to be corrected. Duties may also include the generation of various statistical report to track these errors. Makes appropriate recommendations for changes or solutions and facilitate corrective action when applicable. * Identifies reviews, verifies, and corrects all statistical data concerning MR post reports. * Develops and compiles written reports trending provider specific, service, and hospital compliance reports regarding admission subsequent and discharge notes. * Identifies and abstracts information from health records for special studies and audits both internal and external. Work Schedule: Monday-Friday; 8:00am to 4:30pm EST. Telework: Not Available Virtual: This is not a virtual position. Functional Statement #: 91207-0, 91208-0, 91209-0, 91210-0 Relocation/Recruitment Incentives: Not authorized Permanent Change of Station (PCS): Not Authorized Pay: Competitive salary and regular salary increases. When setting pay, a higher step rate of the appropriate grade may be determined after consideration of higher or unique qualifications or special needs of the VA (Above Minimum Rate of the Grade). Paid Time Off: 37-50 days of annual paid time offer per year (13-26 days of annual leave, 13 days of sick leave, 11 paid Federal holidays per year). Selected applicants may qualify for credit toward annual leave accrual, based on prior [work experience] or military service experience. Parental Leave: After 12 months of employment, up to 12 weeks of paid parental leave in connection with the birth, adoption, or foster care placement of a child. Child Care Subsidy: After 60 days of employment, full time employees with a total family income below $144,000 may be eligible for a childcare subsidy up to 25% of total eligible childcare costs for eligible children up to the monthly maximum of $416.66. Retirement: Traditional federal pension (5 years vesting) and federal 401K with up to 5% in contributions by VA Insurance: Federal health/vision/dental/term life/long-term care (many federal insurance programs can be carried into retirement)

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