Medical Records Technician

Job Description

REQUIREMENTS

• 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.
• 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 (https://www.uscis.gov/i-9-central/form-i-9-acceptable-documents). 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.
• 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.

RESPONSIBILITES

• Provides subject matter expertise to Service Line Leaders, and medical center staff.
• Interprets and applies The Joint Commission standards, VA regulations and medico-legal requirements; current Federal Codes pertinent to medical records; Veterans Administration policy memoranda, directives and handbooks pertinent to health information management; ICD-CM coding principles and nomenclature and the MS-DRG system; CPT and E&M rules; medical and procedural terminology; anatomy and physiology, regulations governing confidentiality of medical records; release of information laws and statutes; records management; and any policies pertaining to VA medical records.
• Provides training for HIM, clinical and administrative staff on HIM topics.
• Performs quality improvement projects regarding HIM issues.
• Assists the CHIM or designee in preparing various presentations.
• Performs audits and analyses, preparing and presenting findings and recommendations to the CHIM, Service Line Leaders and medical staff.
• Reviews, analyzes and reports HIM performance monitors.
• Advises Principal Investigators and other clinical staff relating to methodologies of retrieving health care data for specific studies.
• Performs data retrieval for special studies as needed.
• Participates in various VAMC, VISN and national committees requiring health information management subject matter expertise.
• Performs quantitative and qualitative reviews of health record documentation to ensure all patient care data entered in the electronic health record (EHR) is accurate, timely, and completed. Adheres to established documentation requirements as outlined by The Joint Commission (TJC) regulations, Veterans Health Administration (VHA) guidelines, as well as medical-legal requirements. Serves as a liaison in the implementation of automated clinical applications pertaining to the EHR.
• Participates in facility committees and subcommittees related to health information and provides technical advice when necessary.
• Participates in training related to VHA Healthcare Information Systems such as VistA, CPRS and other software packages as they relate to HIM job functions.
• Analyzes clinical and administrative processes related to information flow. Tests and verifies software packages prior to activation in production mode.
• Coordinates with software developers in the local testing of software.

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