Medical Records Technician (Health Information Technology)

Quick Facts

Role: Medical Records Technician (HIT) within a VA health administration service. Work schedule: Monday–Friday, 8:00am–4:30pm. Telework/remote: Not available.

Description

Ensure inpatient and outpatient health records meet regulatory standards and are complete, accurate, and timely. Review electronic and paper documentation for adequacy for patient care, legal requirements, and compliance with CMS, The Joint Commission, and VHA documentation rules. Track record deficiencies, coordinate corrections with clinicians, and expedite record completion for transfers and external requests.

Responsibilities

• Review records for adherence to CMS guidelines, including student/resident supervision and attending physician presence and documentation.
• Maintain a control system to ensure completion of inpatient and outpatient records per VA, The Joint Commission, CMS, and other regulatory standards.
• Adhere to documentation requirements under The Joint Commission regulations, VHA guidelines, and medical-legal requirements.
• Assist clinicians with delinquent/incomplete health records; serve as an expert resource on complete documentation requirements.
• Perform quantitative and qualitative analysis on both computer and paper-based health records.
• Consult with clinicians to clarify conflicting or ambiguous information; identify deficiencies.
• Track deficiencies and ensure corrective actions are completed; resolve deficiency issues in CPRS and seek guidance only when no precedent/procedure exists.
• Expedite completion of health records for patient transfers, legal requests, regulatory agency reviews, and reimbursement purposes.
• Track electronic signatures and document deficiencies; communicate deficiencies to clinical staff via standard routing (in person, internal email, phone, etc.).

Requirements

• U.S. citizenship
• Proficient in written and spoken English
• Subject to background/security investigation
• Selective Service Registration required for males born after 12/31/1959
• Meet basic qualification criteria: 1 year qualifying experience with medical terminology and health records or an associate degree in health information technology/health information management (or related) with required coursework or an equivalent education/experience combination
• Ability to judge whether records are sufficient for regulatory requirements, legal documentation, continuity of patient care, and education/research needs
• Ability to take appropriate action when content is inadequate, inaccurate, untimely, or unreliable
• Ability to communicate orally and in writing to facilitate compliance
• Skill in using appropriate software/computer applications to analyze and document trends
• Ability to apply qualitative and/or quantitative assessment methods
• Ability to work independently and use problem-solving techniques

Benefits

A career with the U.S. government provides a comprehensive benefits package for you and your family; eligibility depends on the position type and whether the role is full-time, part-time, or intermittent.