Medical Records Technician

1 month ago

Wilmington, United States US Veterans Health Administration Full time

**Duties**:
**Duties of a Medical Records (HIT) Technician includes, but not limited to**:

- 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.
- Compiles reports to insure provider specific and service compliance.
- Maintains a control system to ensure completion of all inpatient and outpatient records in accordance with VA, The Joint Commission, CMS and other regulatory agencies standards.
- 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.

**Work Schedule**: Monday - Friday, 8:00 a.m. to 4:30 p.m.

**Compressed/Flexible**:Available.

**Telework**: Not Available.

**Virtual**: This is not a virtual position.

**Requirements**:
**Conditions of Employment**:

- 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 probationary period.
- Subject to background/security investigation.
- Selected applicants will be required to complete an online onboarding process.
- Must pass pre-employment physical examination.
- Participation in the seasonal influenza vaccination program is a requirement for all Department of Veterans Affairs Health Care Personnel (HCP).
- Participation in the Coronavirus Disease 2019 (COVID-19) vaccination program is a requirement for all Veterans Health Administration Health Care Personnel (HCP) - See "Additional Information" below for details.

**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.
- **Experience**: One year of experience equivalent to the next lower level. This is a developmental level for MRT HIT. The MRT HIT at this level receives guidance from the supervisory MRT HIT, or designee, for more complex health records. The MRT HIT analyzes, abstracts, maintains, extracts and compiles information from the health record, working under the review of the supervisor. They 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 accreditation requirements. They coordinate and/or perform health record review activities to satisfy external accreditation requirements and medical center performance measures. The MRT HIT notifies clinical providers regarding incomplete health records. They assist clinical providers regarding completeness of their health record documentation, and the correction of health records. They conduct reviews of incomplete records for individuals clearing the facility. They create and monitor reports to ensure that deficiencies are resolved and completed appropriately. They monitor, verify, correct, and/or upload all transcription/medical speech recognition to maintain completeness and accuracy of health records. MRTs HIT serve as the technical experts in health record content and documentation requirements. **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).

**Grade Determinations**:
***
(a) 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.
- (b) Ability to take appropriate actions if health record content is not adequate, accurate, timely, and/or reliable.
- (c) Ability to communicate both orally and in writing with individuals or groups, to facilitate compliance with established policies and regulations.-
- (f) Ability to work independently and utilize problem-solving techniques in the accomplishment of work.
- **References**: VA Handbook

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