Lead Medical Records Technician (HIT)

This position is located in the Health Information Management (HIM) section at the John D Dingell VA Medical Center. 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. PRINCIPALES MISSIONS : Major duties and responsibilities include but are not limited to the following: Serve as technical expert in health record content and documentation requirements. Responsible for performing quantitative and qualitative reviews of health record documentation. Responsible for ensuring that all patient care data entered in Electronic Health Record (EHR) is accurate, timely, and completed. Adhere to established documentation requirements as outlined by The Joint Commission regulations, Veterans Health Administration (VHA) guidelines, as well as medical-legal requirements. Review records for adherence with CMS guidelines related to student, resident supervision and attending physician presence and documentation. Compile reports to ensure provider specific and service compliance. Maintain 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. Workload Report and contract transcription logs as it relates to timeliness and accuracy of dictated reports completed by medical transcription contractor (as applicable). Review health records for adherence with guidelines related to resident supervision and attending physician presence. Prepare weekly and monthly reports noting the status of all incomplete/delinquent health records and submits the reports to the appropriate administrative and clinical staff. Participate 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. Identify and abstract information from health records for special studies and audits both internal and external. Lead Duties: Facilitates team or unit processes by working in collaboration with team members or employees to ensure that tasks are completed, that good working relationships among team members and with management are maintained, and that team priorities and goals, needs, and achievements are coordinated with management. Performs lead functions over MRT (HIT) positions. Provides guidance and technical direction necessary for accomplishing the work of the unit or team. Serves as work leader, assuring the work assignments of employees in the unit are carried out. Distributes and balances workload and tasks among employees. Assures the timely accomplishment of work assigned to the team. Assures each team member has an integral role in developing the final product or providing the assigned service. Communicates to the team the problem to be solved or program issues under review and coaches the team and/or individual team members in identifying the parameters of a viable solution. Ensures the organization's "vision" is integrated into the team's goals, strategies, activity plans, and work products. Ensures team members participate in both short-term and long-term planning stages of team projects. Continually interacts with team members aimed at building consensus and to serve as negotiator and coach for coordination of team initiatives. 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. Work Schedule: Monday- Friday; 08:00am- 04:30pm. Schedule may be subject to change based on the needs of the Agency. Recruitment/Relocation Incentives (Sign-on Bonus): Not Authorized Permanent Change of Station (Relocation Assi

Salaire : $61,639 – $80,128/Per Year | Avantages : http://www.vacareers.va.gov/why-choose-va/benefits/index.asp

OUR MISSION: To fulfill President Lincoln's promise "To care for those who have served in our nation's military and for their families, caregivers, and survivors" - by serving and honoring the men and women who are America's Veterans. How would you like to become a part of a team providing compassionate whole health care to Veterans? John D. Dingell VA Medical Center in Detroit (Detroit VAMC) is a 160-bed full-service medical center that provides primary, secondary and tertiary care to Veterans in Southeast Michigan. There are approximately 330,000 Veterans residing in the primary service area. The Detroit VAMC is classified as a Level 1B complexity by Veterans Health Administration. We are a teaching hospital, providing a full range of patient care services, with state-of-the-art technology as well as education and research. The facility offers primary care and a full array of medical, surgical and mental health services including Cardiac Care, Cancer Care, Orthopedics, Surgical Servi