Created at: April 09, 2025 00:10
Company: Veterans Health Administration
Location: Lexington, KY, 40501
Job Description:
The incumbent serves as a Medical Records Technician (Health Information Technician) in Pathology and laboratory's Special Reference Laboratory and Anatomic Pathology departments. They review, analyze, abstract, maintain, extracts, and compiles information from health record (Anatomic Pathology report) independently with minimal supervision.
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 HIT must be proficient in spoken and written English Experience and Education. (1) 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. (2) 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). (3) 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: (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. (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 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.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 (HIT), GS-4 (Entry Level) (1) Experience or Education. None beyond basic requirements. (2) 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) (1) Experience. One year of experience equivalent to the next lower level. OR, (2) 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). (3) Demonstrated Knowledge, Skills, and Abilities. In addition to the experience above, the candidate must demonstrate all of the following KSAs: (a) Ability to communicate effectively with internal and external customers. (b) 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). (c) Knowledge of health record documentation guidelines and industry standards. (d) Ability to manage priorities and coordinate work to complete duties within required timeframes. (e) 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 (1) Experience. One year of experience equivalent to the next lower grade level. (2)Demonstrated Knowledge, Skills, and Abilities. In addition to the experience above, the candidate must demonstrate all of the following KSAs: (a) Ability to navigate efficiently through the health record to locate needed information. (b) Ability to analyze health record documentation to ensure compliance with guidelines and industry standards. (c) Skill in investigating potential health record errors and making corrections, when appropriate. (d) Skill in interpreting and applying health information guidelines and using judgment to complete assignments. (e) Ability to follow up on incomplete health record documentation. Medical Records Technician (HIT), GS-7 (Full Performance Level) (1) Experience. One year of experience equivalent to the next lower grade level. (2) Assignment. This is considered the journey level for MRTs HIT. MRTs HIT at this level review, analyze, abstract, maintain, extract, and compile information from the health record independently with minimal supervision. They analyze health records for accuracy, completeness, timeliness, consistency, and compliance with HIM industry standards, policies, procedures, laws, regulations, and accreditation requirements. MRTs HIT prepare complex reports, calculate department statistics, note the status of all incomplete/delinquent records, and submit reports to the appropriate administrative and clinical staff and committees/leadership to ensure deficiencies are resolved and completed appropriately. (3) Demonstrated Knowledge, Skills, and Abilities. In addition to the experience above, the candidate must demonstrate all of the following KSAs: (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. (d) Skill in using appropriate software and computer applications to analyze and record documentation trends. (e) Ability to apply qualitative and/or quantitative methods for assessment and 7 improvement of health records. (f) 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-07. The actual grade at which an applicant may be selected for this vacancy is in the range of GS-04 to GS-07
This position reports to the Troy Bowling Campus at 1101 Veterans Drive, Lexington, KY. The duties of the Medical Records Technician (Health Information Technician) include but are not limited to the following: Utilize transcription software program to transcribe dictations for surgical cytology and autopsy patient reports. Monitor, troubleshoot, correct, and/or upload all transcription/medical speech recognition to ensure complete and accurate surgical, cytology and autopsy patient reports. Ensure all surgical, cytology and autopsy documentation requirements are met for regulatory compliance. Responsible for proper medical terminology, grammar, spelling, punctuation, completeness, and format of surgical, cytology and autopsy patient reports. Work directly with Pathologists to ensure timely and accurate completion of Pathology reports. Organize and maintain draft and final Pathology reports to comply with mandated retention times. Determine and enter correct Current Procedural Terminology (CPT) and Systemized Nomenclature of Medicine (SNOMED) codes into Surgical Pathology final reports with the assistance of the pathologist if needed, to assure facility is reimbursed appropriate revenue per procedure. Prepares all monthly billing invoices for the Special Reference Laboratory by using a combination of Veteran Health Information and Technology Architecture (ViSTA) and Excel for Fiscal services. Receive consult requests from pathologists, retrieve requested pathology slides/blocks for shipment to outside facilities. Ensure pathology materials are sent to correct consulting facility. Receive completed consult reports and include required addendums and or modify original reports to include information from consult report. Maintains HCV registry, monthly updating a transmitted disease workbook with lists of patients with new positive HCV confirmed test results, HBsAG positive test results, and HBcore-IgM positive test results for Transfusion Medicine Service. Utilize CAP website and collaborate with tumor registrar, UKMC, and staff pathologists to ensure current/accurate cancer templates are utilized for patient reports. Ensure pathology slides/blocks sent to outside facilities are documented in Laboratory Disclosure excel spreadsheet for tracking purposes and record of release of personal patient information. Responsible for entering release and return of all original patient pathology slides/blocks. Monitor submission/receipt of cases to outside facilities for consultation. Responsible for investigating delayed or missing reports from outside facilities. Screens samples received from outside facilities and resolves sample problem issues including missing, leaking, late, and samples with inadequate sample volume for testing. Receives and accessions all samples received from outside facilities using Laboratory Electronic Data Interface (LEDI) and manual ViSTA accessioning as appropriate. Assists with labeling and putting away samples for future testing and ensures all patient information is correct. Provides direction about shipping and handling of laboratory samples. Maintains a computer file with relevant information for clients who send samples to SRL and provides information to other medical personnel as needed. Responds to requests for information and resolves a variety of inquiries, complaints, and concerns by staff (locally, academic affiliates and from other VA Medical Centers). Monitor completion status of consults and outside testing reports. Contact outside facilities for any delayed or missing reports to ensure turnaround time requirements are met. Maintain complete consult records for quality assurance. Field and triage requests for molecular testing in Anatomic Pathology. Completes appropriate requisitions with required information. Pulls case history from ViSTA and retrieves corresponding slides for review by pathologist for send out approval. Utilizes molecular testing portal to enter patient information for test submission. Coordinates specimen pickup and tracks specimens sent for testing to ensure timely completion of results. Scans completed molecular genetics final reports into patient report and ensures the modified report is reviewed and signed again by the appropriate pathologist. Work Schedule: Monday - Friday | 0800-1630 Campus: Troy Bowling Campus Telework: Not Available Virtual: This is not a virtual position. Functional Statement #: 30266F - 30825F - 30826F - 30827F Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized