Medical Records Technician (Health Information Technician)

About the role

CRITICAL Shortage LIST OIG: 38 U.S.C. 7412 waives the requirement to apply Veterans' preference to external applicants for appointments made during the fiscal year to hybrid title 38 occupations among those reported to have the largest staffing shortages. This position is located in the Health Information Management (HIM) section at the VA Maryland Healthcare Center.

Medical Records Technician (Health Information Technician) perform incomplete health record analysis.

What you will do

• GS 4 - ENTRY LEVEL Responsible for abstraction of clinical information for ongoing regulatory reviews and deficiency analysis.
• Contacts physicians and other ancillary service personnel regarding dictation and/or signatures.
• Communicates very closely with the clinical staff to answer questions and resolve problems to ensure quality documentation in the health records.
• Utilizes basic knowledge of medical terminology, anatomy and physiology, and coding to research and collect information for various medical studies and research projects.
• Monitors house staff rotation schedule and contacts resident house staff to ensure completion of health records prior to departure from the Medical Center.
• Coordinates review activities with the Quality Improvement Program to satisfy external accreditation requirements, and to satisfy current Medical Center performance measures.
• GS 5 - DEVELOPMENTAL LEVEL 1 Responsible for abstraction of clinical information for ongoing regulatory reviews and deficiency analysis.
• Assists clinical staff by providing information regarding required documentation.
• Tracks unsigned / uncosigned notes (e.g., progress notes, operative reports, discharge summaries, etc.) and encounters without associated progress notes, and communicates these deficiencies to clinical staff for completion.
• Performs analytical tasks associated with the resolution of "filing" errors on reports uploaded by a transcription vendor.
• Notifies appropriate physician and other personnel of the status of dictation.
• Collects data from data validation activities and audits that support continuity of patient care, budget/resource allocation, performance measurement, quality management, research, VA comparative analysis and benchmarking.
• GS 6 - DEVELOPMENTAL LEVEL Serves as technical expert in health record content and documentation requirements.
• Responsible for performing quantitative and qualitative reviews of health record documentation for ongoing regulatory reviews and deficiency analysis.
• Responsible for ensuring that all patient care data entered in the electronic health record (EHR) is accurate, timely, and complete.
• Adheres to established documentation requirements as outlined by The Joint Commission (TJC) regulations, Veterans Health Administration (VHA) guidelines, as well as medico-legal requirements.
• Reviews health records to ensure that all records contain sufficient information to meet medico-legal requirements, to ensure continuity of patient care, and to support education and research needs.
• Assists clinicians with completion of delinquent / incomplete health records.
• GS 7 - FULL PREFORMANCE LEVEL Serves as technical expert in health record content and documentation requirements.
• Responsible for performing quantitative and qualitative reviews of health record documentation for ongoing regulatory reviews and deficiency analysis.
• Responsible for ensuring that all patient care data entered in the electronic health record (EHR) is accurate, timely, and complete.
• Adheres to established documentation requirements as outlined by The Joint Commission (TJC) regulations, Veterans Health Administration (VHA) guidelines, as well as medico-legal requirements.
• Reviews health records for adherence with the Centers for Medicare and Medicaid Services (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 health records in accordance with VHA, TJC, CMS and other regulatory agencies standards.
• Notifies clinicians of missing, incomplete, or inaccurate information in their signature blocks (e.g., missing or inaccurate credentials).
• Selected applicants may qualify for credit toward annual leave accrual, based on prior [work experience] or military service experience.
• Parental Leave: After 12 months of employment, up to 12 weeks of paid parental leave in connection with the birth, adoption, or foster care placement of a child.
• Child Care Subsidy: After 60 days of employment, full time employees with a total family income below $144,000 may be eligible for a childcare subsidy up to 25% of total eligible childcare costs for eligible children up to the monthly maximum of $416.66.
• Retirement: Traditional federal pension (5 years vesting) and federal 401K with up to 5% in contributions by VA Insurance: Federal health/vision/dental/term life/long-term care (many federal insurance programs can be carried into retirement) Work Schedule: Monday - Friday 8:00 am -4:30 pm Telework: Available Virtual: This is not a virtual position.
• Functional Statement #: 000000 / 000000 / 260368-F / 260283-F Relocation/Recruitment Incentives: Not Available Permanent Change of Station (PCS): Not Authorized

Requirements

• You must be a U.S. Citizen to apply for this job.
• To be considered for this position, you must complete all required steps in the process.
• In addition to the application and questionnaire, this position requires an online assessment.
• The online assessment measures critical general competencies required to perform the job.
• Selective Service Registration is required for males born after 12/31/1959.
• Must be proficient in written and spoken English.
• Subject to background/security investigation.
• Selected applicants will be required to complete an online onboarding process.
• Acceptable form(s) of identification will be required to complete pre-employment requirements (***).
• Effective May 7, 2025, driver's licenses or state-issued identification cards that are not REAL ID compliant cannot be utilized as an acceptable form of identification for employment.
• 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).
• Complete all application requirements detailed in the "Required Documents" section of this announcement.
• As a condition of employment for accepting this position, you will be required to serve a 1 or 2-year trial period during which we will evaluate your fitness and whether your continued employment advances the public interest.
• In determining if your employment advances the public interest, we may consider: your performance and conduct; the needs and interests of the agency; whether your continued employment would advance organizational goals of the agency or the Government; and whether your continued employment would advance the efficiency of the Federal service.
• Upon completion of your trial period, your employment will be terminated unless you receive certification, in writing, that your continued employment advances the public interest.

Education

Basic Requirements: 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).

Medical Records Technician (HIT), GS-5 (Developmental Level 1): 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).

Note: Only education or degrees recognized by the U.S. Department of Education from accredited colleges, universities, schools, or institutions may be used to qualify for Federal employment. You can verify your education here: ***

If you are using foreign education to meet qualification requirements, you must send a Certificate of Foreign Equivalency with your transcript in order to receive credit for that education. For further information, visit: ***

How you will be evaluated

IN DESCRIBING YOUR EXPERIENCE, PLEASE BE CLEAR AND SPECIFIC.

WE MAY NOT MAKE ASSUMPTIONS REGARDING YOUR EXPERIENCE.

Your application, resume, C.V., and/or supporting documentation will be verified. Please follow all instructions carefully. Errors or omissions may affect consideration for employment.

Experience refers to paid and unpaid experience, including volunteer work done through National Service programs (e.g., Peace Corps, AmeriCorps) and other organizations (e.g., professional; philanthropic; religions; spiritual; community; student; social).

Volunteer work helps build critical competencies, knowledge, and skills and can provide valuable training and experience that translates directly to paid employment. You will receive credit for all qualifying experience, including volunteer experience.

The Department of Veterans Affairs performs pre-employment reference checks as an assessment method used in the hiring process to verify information provided by a candidate (e.g., on resume or during interview or hiring process); gain additional knowledge regarding a candidate's abilities; and assist a hiring manager with making a final selection for a position.

It is the policy of the VA to not deny employment to those that have faced financial hardships or periods of unemployment.

Veterans and Transitioning Service Members: Please visit the VA for Vets site for career-search tools for Veterans seeking employment at VA, career development services for our existing Veterans, and coaching and reintegration support for military service members.

Documents you must provide

• Long-form resume/Curriculum vitae (CV) SF-50/ Notification of Personnel Action The following documents are accepted, and may be required if applicable to your eligibility and/or qualifications for this position.
• Please ensure you have included all documents required for your application, such as a copy of your transcript (if using education to qualify), SF-50's (current/former Federal employees), etc. Cover Letter Long-form resume/Curriculum vitae (CV) SF-50/ Notification of Personnel Action Transcript

What to expect next

Once your online application is submitted you will receive a confirmation notification by email. After we receive application packages (including all required documents) and the vacancy announcement closes, we will review applications to ensure qualification and eligibility requirements are met.

After the review is complete, a referral certificate(s) is issued and applicants will be notified of their status by email. Referred applicants will be notified as such and may be contacted directly by the hiring office for an interview. All referred applicants receive a final notification once a selection decision has been made.

You may check the status of your application at any time by logging into your USA Jobs account and clicking on Applications. Information regarding your application status can be found in the USAJobs Help Center. NOTE: Participation in the seasonal influenza program is a condition of employment and a requirement for all Department of Veterans Affairs Health Care Personnel (HCP).

It is a requirement that all HCP to receive annual seasonal influenza vaccination or obtain an exemption for medical or religious reasons. Wearing a face mask is required when an exemption to the influenza vaccination has been granted. HCP in violation of this directive may face disciplinary action up to and including removal from federal service.

HCP are individuals who, during the influenza season, work in VHA locations or who come into contact with VA patients or other HCP as part of their duties. VHA locations include, but are not limited to, VA hospitals and associated clinics, community living centers (CLCs), community-based outpatient clinics (CBOCs), domiciliary units, Vet centers and VA-leased medical facilities.

HCP include all VA licensed and unlicensed, clinical and administrative, remote and onsite, paid and without compensation, full- and part-time employees, intermittent employees, fee basis employees, VA contractors, researchers, volunteers and health professions trainees (HPTs) who are expected to perform any or all of their work at these facilities.

HPTs may be paid or unpaid and include residents, interns, fellows and students. HCP also includes VHA personnel providing home-based care to Veterans and drivers and other personnel whose duties put them in contact with patients outside VA medical facilities.

Additional information

"Whole Health is an approach to health care that empowers and equips people to take charge of their health and well-being and live their life to the fullest. The VA is committed to Whole Health and values Veteran and Employee health and wellbeing.

As a VA employee, you will practice Whole Health in an environment that supports personalized and proactive care." Under the Fair Chance to Compete Act, the Department of Veterans Affairs prohibits requesting an applicant's criminal history prior to accepting a tentative job offer.

For more information about the Act and the complaint process, visit Human Resources and Administration/Operations, Security, and Preparedness (HRA/OSP) at The Fair Chance Act.

Reasonable Accommodation (RA) Requests: If you believe you have a disability (i.e., physical or mental), covered by the Rehabilitation Act of 1973 as amended that would interfere with completing the USA Hire Competency Based Assessments, you will be granted the opportunity to request a RA in your online application.

Requests for RA for the USA Hire Competency Based Assessments and appropriate supporting documentation for RA must be received prior to starting the USA Hire Competency Based Assessments. Decisions on requests for RA are made on a case-by-case basis.

If you meet the minimum qualifications of the position, after notification of the adjudication of your request, you will receive an email invitation to complete the USA Hire Competency Based Assessments, based on your adjudication decision.

You must complete all assessments within 48 hours of receiving the URL to access the USA Hire Competency Based Assessments if you received the link after the close of the announcement.

To determine if you need a RA, please review the Procedures for Requesting a Reasonable Accommodation for Online Assessments. Receiving Service Credit for Earning Annual (Vacation) Leave: Federal Employees earn annual leave at a rate (4, 6 or 8 hours per pay period) which is based on the number of years they have served as a Federal employee.

Selected applicants may qualify for credit toward annual leave accrual, based on prior work experience or military service experience. This credited service can be used in determining the rate at which they earn annual leave. Such credit must be requested and approved prior to the appointment date and is not guaranteed.

During the application process you may have an option to opt-in to make your resume available to hiring managers in the agency who have similar positions. Opting in does not impact your application for this announcement, nor does it guarantee further consideration for additional positions. This job opportunity announcement may be used to fill additional vacancies.

This position is in the Excepted Service and does not confer competitive status. VA encourages persons with disabilities to apply. The health-related positions in VA are covered by Title 38, and are not covered by the Schedule A excepted appointment authority.

If you are unable to apply online or need an alternate method to submit documents, please reach out to the Agency Contact listed in this Job Opportunity Announcement.