Duties and Functions
The Roseburg VA Healthcare System consists of one Veterans Health Administration (VHA) facility located in Roseburg, OR, and three outpatient clinics. RVAHCS also operates a community reintegration service center, consisting of a Homeless Program, Homeless Housing Program with the Department of Health and Human Services (HUD/VASH), Substance Abuse and Vocational Rehabilitation services. Specialty services include Cardiology, Neurology, Infectious Diseases, Optometry, Ophthalmology, ENT, Endocrinology, Urology, Renal, Gerontology, Pulmonary, Gastroenterology, General Surgery, Dermatology and Vocational Rehabilitation.
The incumbent is responsible for abstraction of clinical information for ongoing regulatory reviews. Contacts physicians and other ancillary service personnel regarding dictation and/or signatures, note types, titles, note corrections. Assists medical staff by providing information as to required documentation. Communicates very closely with the medical staff to answer questions and resolve problems to insure quality documentation in the health records.
This is considered the journey level for MRTs HIT. MRTs HIT at this level review, analyze, abstract, maintain, extract, and compile information from the health record independently with minimal supervision. 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 also coordinate and/or perform health record review activities to satisfy external accreditation requirements and medical center performance measures. They communicate regularly with staff at various levels of the organization regarding delinquent health records, and notify individual clinical providers regarding incomplete medical records.
MRTs HIT prepare complex reports, calculate department statistics, note the status of all incomplete/delinquent records, and submit reports to the appropriate administrative and clinical staff and committees/leadership to ensure deficiencies are resolved and completed appropriately. They serve as the expert resource for clinical staff and assist clinical providers with completion or correction of their health record documentation. They conduct the review of incomplete records for individuals clearing the facility. MRTs HIT coordinate the use of medical speech recognition/transcription and monitor, verify, troubleshoot, correct, and/or upload all transcription/medical speech recognition to maintain completeness and accuracy of health records. They serve as the technical expert in health record content and documentation requirements.
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. Incumbent is responsible for ensuring that all patient care data entered in the Electronic Health Record (EHR) 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 inpatient and outpatient records in accordance with VA, The Joint Commission, CMS and other regulatory agencies standards.
- Participates in approved quality improvement focused reviews.
- Coordinates review activities with the Quality Improvement Program to satisfy external accreditation requirements and to satisfy current Medical Center performance measures.
- Assists with capture and reporting of health record documentation deficiencies as needed including downloading data and creating trended reports.
- 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. The incumbent performs the quantitative and qualitative analysis on both electronic and paper-based health records.
- The incumbent assists physicians with the completion of delinquent/incomplete health records and serves as the expert resource for clinical staff regarding requirements for complete documentation.
Work Schedule: Mon - Fri, 8:00am to 4:30pm
Telework: Not applicable, this is a remote position
Virtual: This is not a virtual position.
Functional Statement #: 00000
Relocation/Recruitment Incentives: Not Authorized
Permanent Change of Station (PCS): Not Authorized
Starting at $49,025 Per Year (GS 7)