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Medical Records Technician (Health Information Technician)

Company: Veterans Affairs, Veterans Health Administration
Location: Harlingen
Posted on: June 5, 2021

Job Description:

This position is located in the Health Information Management (HIM) section at VA Texas Valley Coastal Bend Health Care System. Health Information Technicians (HITs) review, analyze, abstract, compile, maintain, and extract information from the health record. They also check for completeness and accuracy of the health record, and monitor and report for regulatory compliance. [ "The Medical Records Technician: serves as technical expert in health record content and documentation requirements. is responsible for performing quantitative and qualitative reviews of health record documentation and for ensuring that all patient care data entered in VistA and/or Computerized Patient Record System (CPRS) is accurate, timely, and completed. Adheres to established documentation requirements as outlined by The Joint Commission regulations, Veterans Health Administration (VHA) guidelines, as well as medical-legal requirements. reviews records for adherence with 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 outpatient records in accordance with VA, The Joint Commission, CMS and other regulatory agencies standards. reviews health records to ensure that all records contain sufficient information to meet medical/legal requirements, to ensure continuity of patient care, and to support education and research needs. Assists clinicians with completion of delinquent/incomplete health records. performs the quantitative and qualitative analysis on patient health records. consults with the appropriate clinician(s) for clarification when conflicting or ambiguous information appears in the health record documentation. identifies health record deficiencies, tracks deficiencies and ensures that the appropriate individual completes their deficiencies. assists physicians with the completion of delinquent/incomplete health records and serves as the expert resource for clinical staff regarding requirements for complete documentation. expedites the completion of the health record when the patient is transferred for care at another medical center, for legal requests, regulatory agencies review, and reimbursement purposes. assesses patient health record in Computerized Patient Record System (CPRS) for completeness and notes deficiencies in the VISTA database. tracks electronic signatures and documents deficiencies and communicates these deficiencies to clinical staff for correction. Notification can be in person, internal e-mail, telephone, or through other normal routing system. works independently resolving health record deficiency issues/erroneous documents and corrective action required within CPRS and only seeks guidance of immediate supervisor and/or Clinical Application Coordinator when issues surface when no precedent or procedure has been developed. prepares complex weekly and monthly reports noting the status of all incomplete/delinquent records and compliance reports and submits the reports to the appropriate administrative and clinical staff. performs analytical tasks associated with the resolution of \"filing\" errors on reports uploaded by file clerks. This includes correctly identifying the patient the report belongs too and filing/assigning it correctly generates various statistical reports to track these errors. identifies reviews, verifies, and corrects all statistical data concerning indexing workload to maintain accuracy of medical and statistical reports. Keeps current and timely reports of all incoming, pending and audited workload and processes. reviews health records for adherence with guidelines related to resident supervision and attending physician presence. works with interdisciplinary staff to solve problems regarding proper health record documentation and completion. prepares weekly and monthly reports noting the status of all incomplete/delinquent health records and submits the reports to the appropriate administrative and clinical staff. conducts monthly record reviews for all clinic sites. participates in routine and focused reviews for the purpose of identifying problems and potential problems in record documentation as part of the health record review process. identifies and abstracts information from health records for special studies and audits both internal and external. Work Schedule: Monday - Friday 8:00 am - 4:30 pm\nFinancial Disclosure Report: Not required" ]

Keywords: Veterans Affairs, Veterans Health Administration, Harlingen , Medical Records Technician (Health Information Technician), Other , Harlingen, Texas

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