Medical Records Technician

Job Summary

This position is located in the Health Administrative Service (HAS) section at the San Diego VA Medical Center. The selected candidate will be responsible for disclosing health information in accordance with all laws and regulations governing authorization and disclosure of health information.

Key Responsibilities

• Evaluate the adequacy of each completed authorization form.
• Screen each request for information to determine urgency and assure that most urgent requests are completed first using established priority systems.
• Personally greet veterans/visitors and assist them in determining the exact nature of the request and whether the information requested can be released.
• Apply 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).
• Process 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 only problem cases to the Supervisor.
• Evaluate the validity of each request.
• Determine 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).
• Ensure that proper authorization exists before release is made.
• Process the request to the requesting agency or individual.
• Input all requests into the ROI computer package for logging and tracking of these requests.
• Receive and direct callers and visitors.
• Receive and/or give out forms and assist visitors and/or callers with the completion of forms or documents.
• Respond to questions from patients concerning services.
• Provide advisory and technical assistance to patients, administrative staff, and professional staff regarding release of information.
• Search records or files to compose responses, including electronic searches to retrieve and summarize hard-to-locate data.
• Locate materials that would verify information given.
• Review paper and computerized health records (i.e., scanned notes, reports, special tests, etc.) to identify material to be photocopied/printed/written to electronic media and released.
• Compose responses to routine requests for release of patient information.
• Select and compile information from health records and prepare correspondence, typically using standard form or standard formats for letters.
• Ensure that the information released is limited to what is specifically authorized and to the person or agency designated to receive it.

Work Schedule

Monday - Friday 7:30 a.m. to 4:00 p.m.

Telework and Virtual Options

This position is not available for telework or virtual work.

Functional Statement #

This position is covered by Functional Statement #.

Relocation/Recruitment Incentives

Not authorized.

Permanent Change of Station (PCS)

Not authorized.

Financial Disclosure Report

Not required.Requirements and 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 probationary period.
• Subject to background/security investigation.
• Selected applicants will be required to complete an online onboarding process.
• 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

• 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.
    • 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.

Grade Determinations

• GS-04 Experience or Education: None beyond basic requirements.
• GS-05 Experience:
  • One year of creditable experience equivalent to the next lower grade level (GS-04).
• 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).
• AND, Demonstrated Knowledge, Skills, and Abilities (KSAs):
  • In addition to the experience above, the candidate must demonstrate all of the following KSAs:
    • 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-06 Experience:
  • One year of creditable experience equivalent to the next lower grade level (GS-05).
• AND Demonstrated Knowledge, Skills, and Abilities (KSAs):
  • In addition to the experience above, the candidate must demonstrate all of the following 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.

Physical Requirements

Light lifting, under 15 lbs., moderate carrying, 15-44 lbs., reaching above shoulder, use of fingers, sitting and/or standing 4-6 hours; hearing, aid permitted.

Duties require extensive use of fingers to perform keyboarding and the ability to hear requests by phone and in person.

Vision must be adequate to read and prepare documents.

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