Medical Records Tech

Summary

VA Portland Health Care System is a Complexity Level 1a Facility and provides extensive primary, secondary, tertiary, and quaternary care in outpatient, inpatient, residential, and community settings. VAPORHCS is a multi-site medical system that includes a major medical facility in Portland, Oregon, outpatient and residential facilities in Vancouver, Washington, and 10 Community Based Outpatient Clinics.

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 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 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: (a) 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
(b) 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: In addition to the Basic Requirements listed above, to qualify for each applicable pay grade, candidates must meet the requirements listed below: GS-4: Experience or Education-None beyond basic requirements
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).Experience and/or education must demonstrated the candidate possesses all the following Knowledge, Skills, and Abilities
In addition to the experience above, the candidate must demonstrate all of the following KSAs (Knowledge, Skills and Abilities): 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.)
Knowledge of health record documentation guidelines and processes for disclosing protected health information
Ability to manage priorities and coordinate work in order to complete duties within required timeframes, and the ability to follow-up on pending issues
Knowledge of policies, procedures, laws, and regulations governing privacy and release of information
Ability to communicate with individuals from various backgrounds to obtain the desired effect or gaining information by establishing rapport
GS-6: Experience-One year of creditable experience equivalent to the next lower grade level (GS-5)Experience must demonstrate the candidate meets the following Knowledge, Skills, and Abilities KSAs: 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)
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
Ability to apply policies, procedures, laws, and regulations governing privacy and release of information to process requests for release of information
Ability to research and solve difficult questions related to release of health information in an accurate and timely manner
References: VA Handbook 5005, PART II APPENDIX G58
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: Light lifting (under 15 pounds), both hands required, hearing (aid may be permitted), mental and emotional stability.
Duties "The duties of this position include but are not limited to the following: The duties in this position are primarily advisory and technical in nature.
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 first 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 medical record, including the Privacy Act, Freedom of Information Act and 38 U.S.C.
7332 governing the release of records containing information regarding the treatment of or referral for drug and/or alcohol abuse, Sickle Cell Anemia and infection with Human Immunodeficiency Virus (HIV).
The incumbent processes all incoming requests to the facility for Release of Information (ROI) along with information required by the VA Regional Office through the Automated Medical Information Exchange (AMIE), referring problem cases to the Supervisor.
Evaluates validity of each request.
Determines which information is to be released in compliance with existing laws (Privacy Act of 1974, Freedom of Information Act, and Health Insurance Portability and Accountability Act).
Ensures that proper authorization exists before release is made.
Processes the request to the requesting agency or individual.
Inputs all requests into the ROI computer package 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.
Employee 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.
Composes detailed explanations in response to correspondence received, arranging information into logical sequence and appropriate format and choosing appropriate words and expressions to convey the desired tone.
Determines extent and tone of replies independently.
Resolves conflicting or inconsistent information found on initial requests.
This involves dealing with patients and/or third parties to resolve discrepancies, sorting out errors and reconstructing past transactions, cases or events, or finding alternative sources of information.
Replies to vague, incomplete, or ambiguous inquires by recognizing issues, topics or problems.
Inquiries are usually presented by patients or third parties who are not sure what information they are looking for or do not know how to identify it by title.
Finds alternative sources of information on which to base a reply when correspondent has provided sketchy or inaccurate information.
Processes Social Security requests for health information using ROI software.
Downloads VistA Imaging documents and ROI software documents onto a secure Network Drive.
Accesses the secured Social Security Web page and uploads the documents to the Web portal.
Transfers the confirmation codes to the ROI software package and closes the requests in both the ROI and Social Security packages.
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 per VA directives.
Processing must be accomplished within established time standards.
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: Monday-Friday 7:30am-4:00pm Telework: Ad-hoc Virtual: This is not a virtual position.
Relocation/Recruitment Incentives: Not Authorized Financial Disclosure Report: Not required"

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