Medical Records Technician (Health Information Technology)

Quick Facts

• Role: Medical Records Technician (Health Information Technology)

• Focus: Incomplete health record analysis and documentation compliance

• Schedule: Monday through Friday, 8:00 AM to 4:30 PM

• Telework: Only if approved on an ad-hoc basis

Description

Serve as a technical expert for health record content and documentation requirements. Review, analyze, abstract, maintain, extract, and compile patient care data to ensure it is accurate, timely, and complete in VistA and/or CPRS. Monitor and report compliance with Joint Commission regulations, VHA guidelines, CMS requirements, and other medical-legal standards.

Responsibilities

• Perform quantitative and qualitative reviews of health record documentation

• Ensure patient care data entered in VistA/CPRS is accurate, timely, and completed

• Review records for compliance with CMS guidance on student/resident supervision and attending physician documentation

• Compile reports to ensure provider-specific and service compliance

• Maintain a control system to ensure completion of inpatient and outpatient records per VA/Joint Commission/CMS standards

• Check records for sufficient information for medical/legal requirements, continuity of care, education, and research

• Assist clinicians in completing delinquent/incomplete records

• Identify deficiencies, track them, and ensure responsible completion; serve as an expert resource for clinical staff

• Expedite completion of health records during transfers, legal requests, regulatory reviews, and reimbursement

Requirements

• U.S. citizenship required

• English proficiency (written and spoken)

• Selective Service registration required for eligible males

• Background/security investigation required

• Online onboarding required

• Seasonal influenza vaccination required

• COVID-19 vaccination required

• Educational/certification requirements must be completed to be hired

• Basic qualification via: 1 year creditable experience in medical terminology/anatomy/physiology/health records OR associate degree in health information technology/health information management (with required coursework) OR qualifying experience/education combination

• For education-based qualification, submit transcripts

Benefits

Comprehensive federal benefits package; eligibility depends on position type.