Summary This Medical Records Technician (Health Information Technician) position is in Business Office Service Line at the CWM VA Healthcare System, located in Leeds Massachusetts This position is full-time at 40 hours per week. Responsibilities This Medical Records Technician (HIT) position is located in the Health Information Management (HIM) section at the CWM Leeds MA VA Healthcare System. MRTs HIT 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. Duties include but are not limited to: Responsible for abstraction of clinical information for ongoing regulatory reviews. Contacts physicians and other ancillary service personnel regarding dictation and/or signatures. Assists medical staff by providing information as to required documentation. Communicates very closely with the medical staff to answer questions and resolve problems to ensure quality documentation in the health records. Provides administrative support for the Medical Center Health Information Program. Review and analyze paper documents for validity/completeness prior to uploading into the EMR. Advise the clinical treatment team on issues related to record completion and documentation requirements. Prepares lists of paper health records needed for signature(s) that are in the incomplete record area for distribution to appropriate service lines (i.e., Medicine, Surgery, Psychiatry, etc.) or that are not complete in the electronic health record. Notifies appropriate physician and other personnel of the status of dictation. Monitors house staff rotation schedule and contacts resident house staff to insure completion of records prior to departure from the Medical Center. Utilizes basic knowledge of medical terminology, anatomy and physiology, and coding to research and collect information for various medical studies and research projects utilizing the Patient Treatment File (PTF) and PTF microfiche. Coordinates review activities with the Quality Improvement Program to satisfy external accreditation requirements and to satisfy current Medical Center performance measures. Assists with capture and reporting of health record documentation deficiencies as needed including downloading data and creating trended reports. Scans and uploads the documentation into the EMR via VistA Image Capture or Doc Manager programs. Participates in performance improvement initiatives within the HIMS department including, but not limited to, daily huddles and monthly staff meetings. Reviews Community Care (CC) consult information to determine if documents pertain to a specific consult. Works closely with CC staff when questions arise regarding the documentation and its connection to the consult. Performs additional duties assigned by management. Work Schedule: 40 Hours a week, Monday- Friday, 7:30am -4:30pm, EST Telework: At Supervisory Discretion Virtual or Remote: This is not a virtual or remote position. Functional Statement #:631-F2383 GS-4,- GS-5 F2382,- GS-6 F2381, GS-7 F2380 Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized Notes: The full Performance of this position is GS-07 The selectee may be promoted to the full performance level (GS-07) without further competition when all regulatory, qualification, and performance requirements are met. Selection at a lower grade level does not guarantee promotion to the full performance level. This position is in the Excepted Service. Excepted Service - "The First year of continuous service in the same and similar position of a preference eligible in the excepted service is a trial period. The first 2 years of continuous service in the same or similar position of an individual in the excepted service (other than a preference), is a trial period." This position is not a Bargaining Unit position. This position is covered by a locality based rate. EDRP is not authorized. Veterans Preference does not apply to this recruitment. Veterans are encouraged to apply and will receive full consideration. Requirements Conditions of Employment You must be a U.S. Citizen to apply for this job. Selective Service Registration is required for males born after 12/31/1959. Must be proficient in written and spoken English. You may be required to serve a trial period. Subject to background/security investigation. Selected applicants will be required to complete an online onboarding process. Acceptable form(s) of identification will be required to complete pre-employment requirements (https://www.uscis.gov/i-9-central/form-i-9-acceptable-documents). Effective May 7, 2025, driver's licenses or state-issued dentification cards that are not REAL ID compliant cannot be utilized as an acceptable form of identification for employment. Must pass pre-employment physical evaluation Participation in the seasonal influenza vaccination program is a requirement for all Department of Veterans Affairs Health Care Personnel (HCP). Qualifications Basic Requirements: United States Citizenship: Non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy. Experience/Education: Experience: One year of creditable experience that indicates knowledge of medical terminology, anatomy, physiology, and a general understanding of health records. Six months of the required one year of creditable experience must have provided the knowledge, skills, and abilities (KSAs) needed to perform MRT HIT work.-OR- Education: An associate degree from an accredited college or university recognized by the U.S. Department of Education with a major field of study in health information technology/health information management, or a related degree with a minimum of 12 semester hours in health information technology/health information management (e.g., courses in medical terminology, anatomy and physiology, medical coding, and introduction to health records). -OR- Experience/Education Combination: Equivalent combinations of creditable experience and education are qualifying for meeting the basic requirements. The following educational/training substitutions are appropriate for combining education and creditable experience: Six months of creditable experience that indicates knowledge of medical terminology, privacy and release of information, the health record, and one year above high school with a minimum of six semester hours of health information technology/health information management.. Six months of creditable experience that indicates knowledge of medical terminology, privacy and release of information, the health record, and successful completion of a course for medical technicians, hospital corpsmen, medical service specialists, or hospital training obtained in a training program given by the U.S. Armed Forces or the U.S. Maritime Service, under close medical and professional supervision, may be substituted on a month-for-month basis for up to six months of experience, provided the training program included courses in anatomy, physiology, and health record techniques and procedures. Grandfathering Provision. All persons employed in VHA as a MRT HIT, on the effective date of this qualification standard, are considered to have met all qualification requirements for the grade held, including positive education and licensure/certification/ registration that are part of the basic requirements of the occupation. For employees who do not meet all the basic requirements in this standard, but who met the qualifications applicable to the position at the time they were appointed to it, the following provisions apply: Such employees in an occupation that does not require a licensure/certification/ registration, may be reassigned, promoted, or demoted within the occupation, but will not be promoted beyond the journey level or placed in supervisory or managerial positions. Employees appointed on a temporary basis prior to the effective date of the qualification standard may not have their temporary appointment extended, or be reappointed on a temporary or permanent basis, until they fully meet the basic requirements of the standard. Employees initially grandfathered into this occupation, who subsequently obtain additional education and/or licensure/certification/registration that meet all the basic requirements of this qualification standard, must maintain the required credentials, as a condition of employment in the occupation. Grade Determinations: GS-04: (Entry Level): None beyond basic requirements. GS-05: (Developmental Level 1):Experience. One year of experience equivalent to the next lower level, GS-04. Duties may include but are not limited to: analyzing health records for accuracy, completeness, timeliness, consistency, and compliance (e.g., scanned, uploaded, use of correct titles, linked to correct encounters, etc.), with HIM industry standards, policies, procedures, laws, regulations, and accrediting bodies; perform health record review activities to satisfy external accreditation requirements and medical center performance measures; monitor, verify, correct, and upload all transcription/medical speech recognition to maintain completeness and accuracy of health records. MRTs HIT receive close supervision from the supervisory MRT HIT or designee. OR Education. A bachelor's degree from an accredited college or university recognized by the U.S. Department of Education with a major field of study in health information management, or a related degree with a minimum of 24 semester hours in health information technology/health information management (e.g., courses in medical terminology, anatomy & physiology, legal aspects of health care, and introduction to health records). AND Demonstrated Knowledge, Skills, and Abilities. In addition to the experience above, the candidate must demonstrate all of the following KSAs: Ability to communicate effectively with internal and external customers. Ability to utilize health information technology and various office software products used in health information management positions (e.g., Microsoft Excel, electronic health records, and delinquency tracking software). Knowledge of health record documentation guidelines and industry standards. Ability to manage priorities and coordinate work to complete duties within required timeframes. Ability to apply knowledge of medical terminology and human anatomy to fully understand the content of a health record. GS-06: Experience. One year of experience equivalent to the next lower grade level, GS-05. AND Demonstrated Knowledge, Skills, and Abilities. In addition to the experience above, the candidate must demonstrate all of the following KSAs: Ability to navigate efficiently through the health record to locate needed information. Ability to analyze health record documentation to ensure compliance with guidelines and industry standards. Skill in investigating potential health record errors and making corrections, when appropriate. Skill in interpreting and applying health information guidelines and using judgment to complete assignments. Ability to follow up on incomplete health record documentation. GS-07: (Full Performance Level): Experience. One year of experience equivalent to the next lower grade level, GS-06. AND Demonstrated Knowledge, Skills, and Abilities. In addition to the experience above, the candidate must demonstrate all of the following KSAs: Ability to judge whether health records contain sufficient information for regulatory requirements, are acceptable as legal documents, are adequate for continuity of patient care, and support education and research needs. Ability to take appropriate actions if health record content is not adequate, accurate, timely, and/or reliable. Ability to communicate both orally and in writing with individuals or groups, to facilitate compliance with established policies and regulations. Skill in using appropriate software and computer applications to analyze and record documentation trends. Ability to apply qualitative and/or quantitative methods for assessment and improvement of health records. Ability to work independently and utilize problem-solving techniques in the accomplishment of work. The full performance level of this vacancy is GS-07. The actual grade at which an applicant may be selected for this vacancy is in the range of GS-4 to GS-07. Physical Requirements: See VA Handbook 5019. References: VA Handbook 5005/124 PART II APPENDIX G59 MEDICAL RECORDS TECHNICIAN (Health Information Technician) QUALIFICATION STANDARD GS-0675 Veterans Health Administration. For more information on this qualification standard, please visit https://www.va.gov/ohrm/QualificationStandards/. Education IMPORTANT: A transcript must be submitted with your application if you are basing all or part of your qualifications on education. Note: Only education or degrees recognized by the U.S. Department of Education from accredited colleges, universities, schools, or institutions may be used to qualify for Federal employment. You can verify your education here: http://ope.ed.gov/accreditation/. If you are using foreign education to meet qualification requirements, you must send a Certificate of Foreign Equivalency with your transcript in order to receive credit for that education. For further information, visit: https://sites.ed.gov/international/recognition-of-foreign-qualifications/. Additional Information During the application process you may have an option to opt-in to make your resume available to hiring managers in the agency who have similar positions. Opting in does not impact your application for this announcement, nor does it guarantee further consideration for additional positions. This job opportunity announcement may be used to fill additional vacancies. This position is in the Excepted Service and does not confer competitive status. VA encourages persons with disabilities to apply. The health-related positions in VA are covered by Title 38, and are not covered by the Schedule A excepted appointment authority. If you are unable to apply online or need an alternate method to submit documents, please reach out to the Agency Contact listed in this Job Opportunity Announcement. Under the Fair Chance to Compete Act, the Department of Veterans Affairs prohibits requesting an applicant's criminal history prior to accepting a tentative job offer. For more information about the Act and the complaint process, visit Human Resources and Administration/Operations, Security, and Preparedness (HRA/OSP) at The Fair Chance Act.
