Summary This position is located in the Health Information Management (HIM) section at the W.G. "Bill" Hefner Salisbury VA Medical Center, Salisbury, NC. The MRT (ROI) reviews and processes requests for patient protected health information (PHI). The MRT (ROI) also provides direct customer service to the Veteran (or third party), by providing copies of the Veteran's PHI, when a signed, written request is received, or upon the Veteran's valid authorization to a third party. Responsibilities Duties include but are not limited to: The duties in this position are primarily advisory and technical in nature. Provides direct customer service to the Veteran, their Personal Representative or third party by providing copies of the Veteran's health information when a signed, written request is received or upon the Veteran's valid authorization to a third party. Incumbent is responsible for evaluating the adequacy of each completed authorization form. Screens each request for information to determine urgency and assures that most urgent requests are completed fist using established priority systems. Personally greets Veterans/visitors and assists them in determining the exact nature of the request and whether the information requested can be released. Applies public laws, rules, regulations, and exclusions governing confidentiality of the health record, including The Privacy Act of 1974, Title 5 United States Code (U.S.C.) § 552a; Department of Veterans Affairs (VA) Claims Confidentiality Statute, 38 U.S.C. § 5701; Confidentiality of Drug Abuse, Alcoholism and Alcohol Abuse, Human Immunodeficiency Virus (HIV) Infection and Sickle Cell Anemia Health Records, 38 U.S.C. § 7332; and the Health Insurance Portability and Accountability Act (HIPAA), Title 45 Code of Federal Regulations (CFR) Parts 160 and 164. The incumbent processes all incoming requests to the facility for ROI along with information required by the VA Regional Office through the Automated Medical Information Exchange (AMIE), referring only problem cases to the Supervisor. For sites that have transitioned to the modernized electronic health record (EHR), utilizes Access HIM Request Management solution for processing of VBA 7131 requests. Evaluates validity of each request. Determines which information is to be released in compliance with existing laws, such as the Privacy Act of 1974, Freedom of Information Act (FOIA), and HIPAA. Ensures that proper authorization exists before release is made. Processes the request to the requesting agency or individual. Inputs all requests into the ROI software for logging and tracking of these requests. Receives and directs callers and visitors. Receives and/or gives out forms and assists visitors and/or callers with the completion of forms or documents. Responds to questions from patients concerning services. Provides advisory and technical assistance to patients, administrative staff, and professional staff regarding release of information. Inquiries vary widely and information given requires explanation of office functions, describing specific requirements, providing basic instructions, or a similar degree of detail. Searches records or files to compose responses, including electronic searches to retrieve and summarize hard-to-locate data. Locates materials that would verify information given. Reviews paper and electronic health records (i.e., scanned notes, reports, special tests, etc.) to identify material to be photocopied/printed/written to electronic media and released. Composes responses to routine requests for release of patient information. Selects and compiles information from health records and prepares correspondence, typically using standard form or standard formats for letters. Ensures the information released is limited to what is specifically authorized and to the person or agency designated to receive it.Completes and processes routine releases of information to other VA and Federal Agencies and when requested, to patients and their families, insurance representatives, physicians, hospitals, and city and state health agencies according to VA directives.Processing must be accomplished within established time standards. Ensures only the information authorized to be released, for the timeframe requested, is included in the disclosure. Accurately enters all requests into the ROI software with necessary information for each request for health information. Completes necessary transactions for deposit of money collected from subpoenas, legal fees, and processing fees for release of information to individuals and insurance companies. Work Schedule: Full-time, Monday - Friday, 8:00am - 4:30pm Telework: Not Available Virtual: This is not a virtual position. Functional Statement #: 000000 Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized Requirements Conditions of Employment You must be a U.S. Citizen to apply for this job. To be considered for this position, you must complete all required steps in the process. In addition to the application and questionnaire, this position requires an online assessment. The online assessment measures critical general competencies required to perform the 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 identification cards that are not REAL ID compliant cannot be utilized as an acceptable form of identification for employment. 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 Applicants pending the completion of educational or certification/licensure requirements may be referred and tentatively selected but may not be hired until all requirements are met. 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 (ROI) 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 and 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 (ROI) 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 and 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 experience and 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 courses. 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 Armed Forces or the U.S. Maritime Service under close medical and professional supervision. The training program may be substituted on a month-for-month basis for up to six months of experience provided the training program included courses in anatomy and physiology, and health record techniques and procedures. May qualify based on being covered by the Grandfathering Provision as described in the VA Qualification Standard for this occupation (only applicable to current VHA employees who are in this occupation and meet the criteria). Grade Determinations: Medical Records Technician (ROI), GS-4 Experience or Education. None beyond basic requirements. Medical Records Technician (ROI), GS-5 Experience. One year of creditable experience equivalent to the next lower grade level; OR, Education. Successful completion of 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 and physiology, legal aspects of health care, and introduction to health records). Demonstrated Knowledge, Skills, and Abilities. In addition to the experience above, the candidate must demonstrate all of the following KSAs: (a) Ability to utilize health information technology and various office software products utilized in MRT (ROI) positions (e.g., the electronic health record, release of information systems, etc.). (b) Knowledge of health record documentation guidelines and processes for disclosing protected health information. (c) Ability to manage priorities and coordinate work in order to complete duties within required timeframes, and the ability to follow-up on pending issues. (d) Knowledge of policies, procedures, laws, and regulations governing privacy and release of information. (e) Ability to communicate with individuals from various backgrounds to obtain the desired effect or gaining information by establishing rapport. Medical Records Technician (ROI), GS-6 Experience. One year of creditable experience equivalent to the next lower grade level. Demonstrated Knowledge, Skills, and Abilities. In addition to the experience above, the candidate must demonstrate all of the following KSAs: (a) Knowledge of the laws and regulations related to the authorization and disclosure of health information (e.g., Privacy Act, Freedom of Information Act, Health Insurance Portability and Accountability Act (HIPAA), and 38 U.S.C. § 7332, Confidentiality of Certain Medical Records). (b) Ability to apply health record documentation guidelines and processes to navigate efficiently through the paper and/or electronic health record to locate, assemble, and disclose protected health information. (c) Ability to apply policies, procedures, laws, and regulations governing privacy and release of information to process requests for release of information. (d) Ability to research and solve difficult questions related to release of health information in an accurate and timely manner. Preferred Experience: At least 1-2 years of experience in a health information management department or a similar medical/administrative setting. Strong background in medical records privacy compliance, Electronic Medial Records (EMR) systems, and patient confidentiality laws like HIPAA. Attention to detail, data entry, medical terminology, computer applications and customer service experience. 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-6. The actual grade at which an applicant may be selected for this vacancy is in the range of GS-4 to GS-6. Physical Requirements: See VA Directive and Handbook 5019, Employee Occupational Health Service. 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 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. Reasonable Accommodation (RA) Requests: If you believe you have a disability (i.e., physical or mental), covered by the Rehabilitation Act of 1973 as amended that would interfere with completing the USA Hire Competency Based Assessments, you will be granted the opportunity to request a RA in your online application. Requests for RA for the USA Hire Competency Based Assessments and appropriate supporting documentation for RA must be received prior to starting the USA Hire Competency Based Assessments. Decisions on requests for RA are made on a case-by-case basis. If you meet the minimum qualifications of the position, after notification of the adjudication of your request, you will receive an email invitation to complete the USA Hire Competency Based Assessments, based on your adjudication decision. You must complete all assessments within 48 hours of receiving the URL to access the USA Hire Competency Based Assessments if you received the link after the close of the announcement. To determine if you need a RA, please review the Procedures for Requesting a Reasonable Accommodation for Online Assessments. 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.
