Located in the Health Information Management (HIM) section at the Sheridan Wyoming VA Medical Center. MRTs HIT perform incomplete health record analysis. They review, analyze, abstract, maintain, extract, & compile information from the health record. MRTs HIT check for accuracy, completeness, & timeliness of the health record & monitor & report for regulatory compliance.
Routinely scans paper and electronic documents to the EHR ensuring proper and timely placement in the medical record.
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 ensure 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. 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). Assist 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 unsigned/un-cosigned 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. 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.
If site utilizes Dragon and assigns medical speech recognition (MSR) duties to the HIM Department, coordinates and monitors the use of medical speech recognition and troubleshoots with clinicians, as needed, to maintain completeness and accuracy of health records.
Provides Dragon Local Administrator duties that typically include: creating new user accounts in the Nuance Management Center, act as a local POC for Dragon questions, referrals and guidance, troubleshoot technical problems with local IT as needed, assist clinical end users with log on and provide user guides, create and maintain a facility Dragon User Outlook mail group to facilitate MSR communications, submit tickets to Nuance Government Support, as needed, listen in and participate on the VHA MSR Administration calls, provide training tools and resources, facilitate purchase and distribution of headsets/microphones as needed, and provide Dragon usage reports to leadership.
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. Prepares complex reports on a routine basis, noting the status of all incomplete/delinquent health records, and submits the reports to the appropriate administrative and clinical staff.
Develops and compiles written reports trending provider specific, service, and hospital compliance reports regarding admission, subsequent and discharge progress notes. Obtains statistical information, applies statistical formulas, and completes statistical reports for medical center management. Work Schedule: Monday - Friday, 7:30am - 4:00pm Telework: Available on an ad-hoc basis. Virtual: This is not a virtual position.
Functional Statement #: 61593-0 / 61594-0 / 61595-0 / 61596-0 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/.
V19USAJOBS@VA.GOV · 719-227-4600
This position is with Veterans Health Administration, Department of Veterans Affairs.
The posted pay range is $36409 – $65599/yr.
This position is eligible for telework.
Applications close on 2026-10-07.
This position is open under the 'Fed Competitive' hiring path.
Source: USAJOBS.gov — U.S. Federal Government
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