Duties

Summary

The incumbent functions as an expert authority on the medic-legal requirements for release of health information, this position is located in the Medical Administration Service at the Baltimore Campus, Veterans Administration Maryland Health Care System.

Learn more about this agency

Responsibilities

Monitors and controls the timely and accurate release of medical information to authorized requestors to assure full compliance with the Privacy Act of 1974, Freedom of Information Act (FOIA), Health Insurance Portability and Accountability Act (HIPAA) and other Federal and State laws as well as VHA regulations and policies.

Screens each request for the nature and purpose of the inquiry and determine availability of the information requested. Determines the identity of the patient and assures each authorization contains proper authorization to release the information requested. Furnishes the information in the printed or copied format of the medical record documents depending of the medium used to retrieve the information (automated/electronic or manual/paper medical record). These requests come from a variety of sources and may require different responses; must review each request and/or interview requestors to ascertain the desired information. In the event of a valid emergency, furnishes information by telephone to Health Care providers and notifies patient or legal guardian of the type of information released. (15%)

Each request is reviewed to determine:

The purpose and legitimacy of the request under the Privacy Act, the Freedom of Information Act (FOIA) and VHA regulations and policies.

Whether or not the request falls under "Routine Use" and if not, that there is a current authorization properly dated and signed by a competent patient or for an incompetent or deceased patient, by the legal guardian or nearest relative.

Whether or not the record contains drug or alcohol related information, treatment for HIV/AIDS or sickle cell anemia, which may or may not be released except with special authorization.

Whether or not the medical records contain sensitive information would not be detrimental to the patient's health or welfare.

Whether or not a fee is appropriate and informs the requestor of the proper payment before information is released.

Identification of cases in which information may be provided without consent in emergency situations such as over the phone or by facsimile.

Acts as a liaison between the VA Regional Office and the Medical Center for the purpose of furnishing medical record documents to be used as the basis for adjudication of claims for benefit. Ensures that the electronic control file on Regional Office request and is updated and all disclosures are documented as required by the Privacy Act, FOIA and VA regulations.

Reviews records of patient who request personal review of their records and makes the initial decision concerning the sensitivity of the record and the necessity of referring the record for final physician review. Arranges appointment for patients and/or their authorized representative to review records and is present during the review. Prepares letters of denial to review or amend records with appeal information provided for concurrence by Unit Supervisor.

Compiles tort cases for the Regional Office. Prepares certified copies of medical records for use in court proceedings. This requires extensive investigations to track down x-rays and medical records to compile a complete medical record. Contacts all VA's have them make a CD of all of the photocopied/printed/written to electronic media information, including digital x-rays. All paper records are arranged in date order, numbered and several exact copies made for the Regional Office. All computer records are downloaded to a CD including documents in VistA Imaging. For cases going to trial, this may include additional updates and coordination with the US Attorney's Office.

Ensures all records are 100% complete, properly sequenced, and numerically recorded in accordance with legal requirements. Prepares required number of copies for various VA offices, and ensures original record is safeguarded. Compliance with established procedures is mandatory to ensure the VA is not liable based on accuracy of documentation of the medical record.

Completes and processes routine releases of information to other VA and Federal Agencies and when requested, to patients and their families, insurance representatives, physicians, hospitals, and city and state health agencies according to VA directives. Processing must be accomplished within established time standards. Accurately enters all requests into the DSS ROI software with necessary information for each request for medical information. Completes necessary transactions for deposit of money collected from subpoenas, legal fees, and processing fees for release of information to individuals and insurance companies.

*Other duties as assigned or further defined in full Functional Statement.

Work Schedule: Monday to Friday 8:00 AM - 4:30 PM

Financial Disclosure Report: Not required

Travel Required

Not required

Supervisory status
No

Promotion Potential
6

Requirements

Conditions of Employment

• You must be a U.S. Citizen to apply for this job
• Designated and/or random drug testing may be required
• Selective Service Registration is required for males born after 12/31/1959
• You may be required to serve a probationary period
• Subject to a background/security investigation
• Must be proficient in written and spoken English
• Selected applicants will be required to complete an online onboarding process

Qualifications

Basic Requirements:

• United States Citizenship: Non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy.
• English Language Proficiency: MRTs (ROI) must be proficient in spoken and written English, as required by 38 U.S.C. § 7403(f).

Experience and Education:

• Experience: One year of experience that indicates knowledge of medical terminology, anatomy, physiology, and a general understanding of health records. Six months of the required one year of experience must have provided the knowledge, skills and abilities (KSAs) need to perform MRT work.

OR

• Education: 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).
  

OR

• Experience/Education Combination: Equivalent combinations of experience and education are qualifying. The following education/training substitutions are appropriate for combining education and experience:
• Six months of creditable experience that indicates knowledge of medical terminology, privacy and release of information, the health record, and one year above high school with a minimum of six semester hours of health information technology/health information management.
  
• Six months of creditable experience that indicates knowledge of medical terminology, privacy and release of information, the health record, and successful completion of a course for medical technicians, hospital corpsmen, medical service specialists, or hospital training obtained in a training program given by the U.S. Armed Forces or the U.S. Maritime Service, under close medical and professional supervision, may be substituted on a month-for-month basis for up to six months of experience, provided the training program included courses in anatomy, physiology, and health record techniques and procedures.
  

Grade Determinations:

• GS-6: One year of experience equivalent to the next lower grade level (GS-5).

This is a developmental level for MRT. The MRT at this level receives guidance from the supervisory MRT, or designee, for more complex health records. The MRT analyzes, abstracts, maintains, extracts and compiles information from the health record, working under the review of the supervisor. They analyze health records for accuracy, completeness, timeliness, consistency, and compliance (e.g., scanned, uploaded, use of correct titles, linked to correct encounters, etc.) with HIM industry standards, policies, procedures, laws, regulations, and accreditation requirements. They coordinate and/or perform health record review activities to satisfy external accreditation requirements and medical center performance measures. The MRT notifies clinical providers regarding incomplete health records. They assist clinical providers regarding completeness of their health record documentation, and the correction of health records. They conduct reviews of incomplete records for individuals clearing the facility. They create and monitor reports to ensure that deficiencies are resolved and completed appropriately. They monitor, verify, correct, and/or upload all transcription/medical speech recognition to maintain completeness and accuracy of health records. MRTs serve as the technical experts in health record content and documentation requirements.

In addition to the experience above, the candidate must demonstrate all of the following KSAs:

Ability to communicate effectively with internal and external customers.

Ability to utilize health information technology and various office software products used in health information management positions (e.g., Microsoft Excel, electronic health records, and delinquency tracking software).

Knowledge of health record documentation guidelines and industry standards.

Ability to manage priorities and coordinate work to complete duties within required timeframes.

Ability to apply knowledge of medical terminology and human anatomy to fully understand the content of a health record.

References: VA Handbook 5005, Part II, Appendix G35

Physical Requirements: The work involved in this position is mostly sedentary, with long periods sitting at computer desk. Some walking and long periods of standing may be required.

Education

IMPORTANT: A transcript must be submitted with your application if you are basing all or part of your qualifications on education.

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: http://ope.ed.gov/accreditation/ . 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: http://www.ed.gov/about/offices/list/ous/international/usnei/us/edlite-visitus-forrecog.html .

Additional information

This job opportunity announcement may be used to fill additional vacancies.

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

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.

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.

If you are unable to apply online view the following link for information regarding an Alternate Application .

How You Will Be Evaluated

You will be evaluated for this job based on how well you meet the qualifications above.

IN DESCRIBING YOUR EXPERIENCE, PLEASE BE CLEAR AND SPECIFIC. WE MAY NOT MAKE ASSUMPTIONS REGARDING YOUR EXPERIENCE. Your application, résumé, C.V., and/or supporting documentation will be verified. Please follow all instructions carefully. Errors or omissions may affect consideration for employment.

RESUME REMINDER: Your resume must include the following information for each job listed:

Job title Duties (be as detailed as possible)
Month & year start/end dates (e.g. June 2007 to April 2008)
Full-time or part-time status (include hours worked per week)

Please be aware that your answers will be verified against information provided on your resume. Be sure that your resume clearly supports your responses to all of the questions by addressing your work experience in detail.

Recommended: Even though we do not require a specific resume format, your resume must be clear so that we are able to fully evaluate your qualifications. To ensure you receive appropriate consideration, please list the duties you performed under each individual job title. If we are unable to match your experiences with the positions held, you may lose consideration for this vacancy. In addition, please be sure to include your Education Month and year start/end dates. We cannot make assumptions regarding your qualifications.

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.

Background checks and security clearance

Security clearance
Other

Drug test required
No

Position sensitivity and risk
Non-sensitive (NS)/Low Risk

Trust determination process
Suitability/Fitness

Required Documents

To apply for this position, you must provide a complete Application Package which includes:

• Resume

The following documents are accepted, and may be required if applicable to your eligibility and/or qualifications for this position. Please use this checklist to 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
• DD-214/ Statement of Service
• Disability Letter (VA)
• Resume
• SF-15
• SF-50/ Notification of Personnel Action
• Transcript

Veterans' Preference: When applying for Federal Jobs, eligible Veterans should claim preference for 5pt (TP), 10pt (CP/CPS/XP), or for Sole Survivor Preference (SSP) in the questionnaire. You must provide a legible copy of your DD214(s) which shows dates and character of service (honorable, general, etc.). If you are currently serving on active duty and expect to be released or discharged within 120 days you must submit documentation related to your active duty service which reflects the dates of service, character of service (honorable, general, etc.), and dates of impending separation. Additionally, disabled veterans and others eligible for 10-point preference (such as widows or mothers of eligible Veterans) must also submit an SF-15 "Application for 10 Point Veteran Preference" with required proof as stated on the form. Documentation is required to award preference. For more information on Veterans' Preference, please visit http://www.fedshirevets.gov/job/vetpref/index.aspx .

If you are relying on your education to meet qualification requirements:

Education must be accredited by an accrediting institution recognized by the U.S. Department of Education in order for it to be credited towards qualifications. Therefore, provide only the attendance and/or degrees from schools accredited by accrediting institutions recognized by the U.S. Department of Education .

Failure to provide all of the required information as stated in this vacancy announcement may result in an ineligible rating or may affect the overall rating.