This position is located in the Health Information Management (HIM) section at the Southeast Louisiana Veterans Healthcare System (SLVHCS). MRTs HIT perform incomplete health record analysis. They review, analyze, abstract, maintain, extract, and compile information from the health record. MRTs HIT check for accuracy, completeness, and timeliness of the health record and monitor and report for regulatory compliance.
The duties of the Medical Records Technician (Health Information Technician) include, but are not limited to: The incumbent is responsible for abstraction of clinical information for ongoing regulatory reviews and deficiency analysis. Contacts physicians and other ancillary service personnel regarding dictation and/or signatures. Assists clinical staff by providing information as to required documentation.
Communicates very closely with the clinical staff to answer questions and resolve problems to ensure quality documentation in the health records. Assists with capture and reporting of health record documentation deficiencies and notates documentation deficiencies in the appropriate deficiency monitoring application.
Monitors delinquent dictation list for follow-up purposes on necessary documents (i.e., operation reports, discharge summaries, etc.) that are needed for completion of health records. Notifies appropriate physician and other personnel of the status of dictation. Monitors house staff rotation schedule and contacts resident house staff to ensure completion of health records prior to departure from the Medical Center. Participates in approved quality improvement focused reviews.
Utilizes basic knowledge of medical terminology, anatomy and physiology, and coding to research and collect information for various medical studies and research projects. Coordinates review activities with the Quality Improvement Program to satisfy external accreditation requirements and to satisfy current Medical Center performance measures.
Collects data from data validation activities and audits that support continuity of patient care, budget/resource allocation, performance measurement, quality management, research, VA comparative analysis and benchmarking. 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.
Assists with capture and reporting of health record documentation deficiencies and notates documentation deficiencies in the appropriate deficiency monitoring application. Monitors delinquent dictation list for follow-up purposes on necessary documents (i.e., operation reports, discharge summaries, etc.) that are needed for completion of health records. Notifies appropriate physician and other personnel of the status of dictation.
Monitors house staff rotation schedule and contacts resident house staff to ensure completion of health records prior to departure from the Medical Center. Assists physicians with the completion of delinquent/incomplete health records and servers as the expert resource for clinical staff regarding requirements for complete 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. Reviews health records to ensure that all 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. Works independently to resolve incomplete health record deficiency and erroneous documentation issues and only seeks guidance of immediate supervisor when issues surface where no precedent or procedure has been developed.
Collects, interprets, and trends data from data validation activities and audits that support continuity of patient care, budget/resource allocation, performance measurement, quality management, research, VA comparative analysis and benchmarking. Participates in routine and focused reviews for the purpose of identifying problems and potential problems in health 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, 7:30 am - 04:00 pm, (Subject to change based on the needs of the facility.) Telework: Available Virtual: This is not a virtual position. Functional Statement #: 01300F, 01301F, 01437F, 01438F Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized
Preferred Experience: Tech-savvy; quickly learns new software, EHR, and deficiency-tracking/health information systems. Intermediate to expert Microsoft Office (Word, Excel, PowerPoint, Outlook), including generating statistical/compliance reports and analyzing data. Experience conducting quantitative and qualitative health record reviews for regulatory compliance (TJC, CMS, VHA).
Familiarity with medical speech recognition (e.g., Dragon/Nuance) and transcription workflows, including troubleshooting and local administration. Skill in tracking, trending, and reporting health record deficiencies and communicating them to clinical staff. Experience delivering presentations and developing training for clinical and non-clinical staff on documentation requirements.
Able to manage multiple concurrent projects and competing deadlines while maintaining accuracy. LEAN (or Lean Six Sigma) training or certification. Reference: For more information on this qualification standard, please visit https://www.va.gov/ohrm/QualificationStandards/. The full performance level of this vacancy is GS-07. The actual grade at which an applicant may be selected for this vacancy is in the range of GS-04 to GS-07.
Physical Requirements: Physical Demands: Physical aspects associated with work required of this assignment are typical for this occupation, see duty section for essential duties of this position. May require standing, lifting, carrying, sitting, stooping, bending,, pulling, and pushing. May be required to wear personal protective equipment and undergo annual TB screening or testing as conditions of employment.
Work Environment: Work is performed in an office clinic setting with minimal risks that requires normal safety precautions; the area is adequately lighted heated and ventilated. However, the work environment requires someone with the ability to handle several tasks at once and sometimes stressful situations. 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/.
caesare.toliver@va.gov · 504-326-7620
This position is with Veterans Health Administration, Department of Veterans Affairs.
The posted pay range is $37193 – $65599/yr.
This position is eligible for telework.
Applications close on 2026-10-28.
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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