Medical Records Technician (Health Information Technician)

This position is located in the Health Information Management Section (HIMS) of the Health Administration Service (HAS) at the Michael E. DeBakey VA Medical Center. Health Information Technicians (HITs) review, analyze, abstract, compile, maintain, and extract information from the health record. They also check for completeness and accuracy of the health record and monitor and report for regulatory compliance. If you are not a current, permanent VA employee or Federal employee from another agency, you should apply to CBST-12924920-26-MJH. Total Rewards of a Allied Health Professional The duties of the Medical Records Technician (Health Information Technician) mayinclude but are not limited to: * Serves as technical expert in health record content and documentation requirements. * Performs quantitative and qualitative reviews of health record documentation. * Ensures 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. * 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. * Consults with the appropriate clinician(s) for clarification when conflicting or ambiguous information appears in the health record documentation. * Performs the quantitative and qualitative analysis on both computer and paper-based health records. * 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. * 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. * 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. Work Schedule: Monday-Friday, 07:30 am - 4:00 pm (subject to change based on the needs of the facility) Relocation Incentive (Sign-on Bonus): Not Authorized Permanent Change of Station (Relocation Assistance): Not Authorized Pay: Competitive salary and regular salary increases. 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). 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) Telework: Not Available Virtual: This is not a virtual position. Functional Statement #: 580-00155-F; 580-00156-F; 580-00157-F; 580-00158-F Permanent Change of Station (PCS): Not Authorized

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