This position is located in the Health Information Management (HIM) section of the Health Administrative Service (HAS) at the St Cloud VA Medical Center (SCVA-HCS). MRT (HIT) perform incomplete health record analysis. They review, analyze, abstract, maintain, extract, and compile information from the health record. MRT (HIT) check for accuracy, completeness, and timeliness of the health record and monitor and report for regulatory compliance.
The incumbent is required to physically report to and work from the St. Cloud, MN office Major Duties includes, but are not limited to: Incumbent serves as technical expert in health record content and documentation requirements. Incumbent is responsible for performing quantitative and qualitative reviews of health record documentation for ongoing regulatory reviews and deficiency analysis.
Incumbent is responsible for ensuring that all patient care data entered in the electronic health record (EHR) is accurate, timely, and complete. 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 Veterans Health Administration (VHA), The Joint Commission (TJC), CMS and other regulatory agencies standards. Reviews health records to ensure that all health records contain sufficient information to meet medico-legal requirements, to ensure continuity of patient care, and to support education and research needs.
Notifies clinicians of missing, incomplete, or inaccurate information in their signature blocks (e.g., missing or inaccurate credentials). Assists clinicians with completion of delinquent/incomplete health records. Assesses the health record for completeness, identifies health record deficiencies, tracks deficiencies, and ensures that the appropriate individuals complete their deficiencies.
Notates documentation deficiencies in the appropriate deficiency monitoring application. Tracks electronic signatures and documents deficiencies and communicates these deficiencies to clinical staff for correction. Notification can be in person, through secure email, via telephone, or through other acceptable means.
Responsible for expediting 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. Performs analytical tasks associated with the resolution of "filing" errors on reports uploaded by a transcription vendor. This includes correctly identifying the patient the report belongs to and filing/assigning it correctly.
Duties includes the generation of various statistical reports to track these errors. Makes appropriate recommendations for changes or solutions and implements appropriate recommendations for corrective action when authorized so continued filing errors do not occur. Works with interdisciplinary staff to solve problems regarding proper health record documentation and completion.
Consults with the appropriate clinician(s) for clarification when conflicting or ambiguous information appears in the health record documentation. Performs administrative corrections to the health record, such as correcting note titles, designating correct signer/cosigner, ensuring notes are attached to the correct episode of care, etc.
Utilizes EHR functionality to analyze, manage and monitor documentation and data capture deficiencies and to communicate with staff to resolve deficiencies in accordance with facility policies and performance goals. Identifies incomplete health records for individuals clearing the facility and assists clinicians with the clearance process for health records. Work Schedule: Monday-Friday, 7:30am-4:00pm Telework: Not Available Virtual: This is not a virtual position.
Functional Statement #: 000000 Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized
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: https://sites.ed.gov/international/recognition-of-foreign-qualifications/. The VA Midwest Health Care Network advocates for a Whole Health System of care in each of the Medical Centers. This is an approach to healthcare that empowers and equips people to take charge of their health and well-being and live their lives to the fullest.
As an employee operating in a Whole Health System of care, you will operate in a model with three core elements, seeking to create a personalized health plan for each Veteran. This is done in the context of healing relationships and healing environments and a connection back to the Veteran's community.
This aligns with the Veterans Health Administration (VHA) Mission Statement to Honor America's Veterans by providing exceptional health care that improves their health and well-being.
Megan.noe@va.gov · (724) 285-2259
This position is with Veterans Health Administration, Department of Veterans Affairs.
The posted pay range is $39694 – $71517/yr.
This position requires a Other security clearance.
Applications close on 2026-10-27.
This position is open under the 'Fed Internal Search' hiring path.
Source: USAJOBS.gov — U.S. Federal Government · Retrieved 2026-10-20 · Not affiliated with or endorsed by OPM or USAJOBS.gov
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