Summary NOTE: THE 2-PAGE RESUME REQUIREMENT DOES NOT APPLY TO THIS OCCUPATIONAL SERIES. FOR MORE INFORMATION, REFER TO REQUIRED DOCUMENTS BELOW Position is in the Health Information Management (HIM) section of the Health Administration Service (HAS) service line. The Medical Records Technician (MRT) is responsible for reviewing, analyzing, organizing, abstracting, processing, and maintaining clinical and administrative documents in any medium. Responsibilities Total Rewards of a Allied Health Professional Position involves technical work concerned with processing and maintenance of medical records. Work requires practical knowledge of human anatomy, physiology, medical terminology, and legal requirements of the medical record. Analytical ability, judgement, discretion and a high level of tact and negotiating are required on a daily basis to carry out functions of this position. Functions Responsible for Providing administrative support for the Medical Center Health Information Program Abstraction of clinical information for ongoing regulatory reviews Applying practical knowledge of laws and regulations of HIM Apply knowledge of medical terminology, human anatomy/physiology and disease processes. Navigate efficiently through the electronic medical record. Understands internal organization of medical records and medical record references. Abstracts clinical information for ongoing regulatory medical record reviews. Validates data collected, creates status reports and provides prepared data to HIMS management. Coordinates review activities with the Quality Improvement Program to satisfy external accreditation requirements and performance measures. Reads and abstracts medical information. Assure information being reviewed is accurate. Works with the HIM team to identify medical record review trends and documentation discrepancies. Reviews abstracted information. Will be used for medical record completion. Tracks incomplete reports for completion using various systems. Upload clinical reports. Prepares Medical Record Review Data, Reports, Statistics and Quality Reviews that show current trends. The Medical Record Review Data will be presented and explained to the Assistant Chief and Chief of Health Information monthly. Reviews, analyzes and reports HIM performance monitors for coding and other medical record review topics. Reviews documentation corrections to ensure coded data reflects any change in documentation; makes coding changes as appropriate. Performs audits and analyses, preparing and presenting findings and recommendations. Provides professional consultation, management assistance and health record support. Tracks electronic signatures and documents deficiencies and communicates these deficiencies to clinical staff for correction. Works independently resolving health record deficiency issues/erroneous documents and corrective action required. Prepares complex reports noting the status of all incomplete/delinquent records and compliance reports. Preforms analytical tasks associated with the resolution of "filing" errors on reports uploaded by a transcription vendor. Identifies reviews, verifies, and corrects all statistical data concerning medical transcription. Compares and resolves discrepancies. Reviews health records for adherence with guidelines. Works with interdisciplinary staff. Develops and compiles written reports trending provider specific, service, and hospital compliance reports regarding admission subsequent and discharge notes. Obtains statistical information, applies statistical formulas, and completes statistical reports for medical center management. Work Schedule: Monday-Friday, 8am-4:30pm Recruitment Incentive (Sign-on Bonus): Not authorized Permanent Change of Station (Relocation Assistance): 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) Telework: AD-HOC Virtual: This is not a virtual position Functional Statement #: 000000 Permanent Change of Station (PCS): Not authorized 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. 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). Complete all application requirements detailed in the "Required Documents" section of this announcement. As a condition of employment for accepting this position, you will be required to serve a 1 or 2-year trial period during which we will evaluate your fitness and whether your continued employment advances the public interest. In determining if your employment advances the public interest, we may consider: your performance and conduct; the needs and interests of the agency; whether your continued employment would advance organizational goals of the agency or the Government; and whether your continued employment would advance the efficiency of the Federal service. Upon completion of your trial period, your employment will be terminated unless you receive certification, in writing, that your continued employment advances the public interest. Qualifications NOTE: THE 2-PAGE RESUME REQUIREMENT DOES NOT APPLY TO THIS OCCUPATIONAL SERIES. FOR MORE INFORMATION, REFER TO REQUIRED DOCUMENTS BELOW To qualify for this position, applicants must meet all requirements within 30 days of the closing date of this announcement. 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. English Language Proficiency: MRTs HIT must be proficient in spoken and written English, as required by 38 U.S.C. § 7403(f). Experience and 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'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 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, physiology, legal aspects of health care, and introduction to health records). OR Experience/Education Combination: Equivalent combinations of creditable experience and education are qualifying towards meeting basic experience 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. Grade Determinations: Medical Records Technician (HIT), GS-4 (Entry Level) Experience or Education: None beyond basic requirements. Assignment: Employees at this level serve as entry level MRTs HIT, and receive close supervision from the supervisory MRT HIT or designee. MRTs HIT analyze 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. They perform health record review activities to satisfy external accreditation requirements and medical center performance measures. They monitor, verify, correct, and upload all transcription/medical speech recognition to maintain completeness and accuracy of health records. Medical Records Technician (HIT), GS-5 (Developmental Level 1) Experience: One year of experience equivalent to the next lower level. 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). 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. Medical Records Technician (HIT), GS-6 Experience: One year of experience equivalent to the next lower grade level. 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. Medical Records Technician (HIT), GS-7 (Full Performance Level) Experience: One year of experience equivalent to the next lower grade level. 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. Reference: For more information on this qualification standard, please visit https://www.va.gov/ohrm/QualificationStandards/. The full performance level of this vacancy is GS-7. The actual grade at which an applicant may be selected for this vacancy is in the range of GS-4 to GS-7. Physical Requirements: This work required light lifting and carrying (under 15lbs), reaching above shoulder, both hands required, ability to see to read materials, and sight is used to read medical documents. 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 Receiving Service Credit or Earning Annual (Vacation) Leave: Federal Employees earn annual leave at a rate (4, 6 or 8 hours per pay period) which is based on the number of years they have served as a Federal employee. Selected applicants may qualify for credit toward annual leave accrual, based on prior work experience or military service experience. This credited service can be used in determining the rate at which they earn annual leave. Such credit must be requested and approved prior to the appointment date and is not guaranteed. 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.
