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Medical Records Technician (Health Information Technician)
Veterans Health Administration · Posted 48 days ago
On-site Cape Coral, FL $36K – $66K Apply by Aug 5, 2026 Medical Records Technician ISFJ HealthcareTrades
Apply for this job → About the Role
This position is located in the Health Information Management (HIM) section of the Business Office at the Bay Pines VA Healthcare System (BPVAHCS). Medical Record Technician (MRTs) Health Information Technician (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.
What You'll Do
- →Total Rewards of a Allied Health Professional Medical Records Technician (Health Information Technician) 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.
- →Medical Record Technician duties and responsibilities include but are not limited to: 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.
- →Ensures 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 insure 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).
- →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.
- →Tracks unsigned/uncosigned 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.
Requirements
- ✓You must be a U.S.
- ✓Citizen to apply for this job.
- ✓All applicants tentatively selected for VA employment in a testing designated position are subject to urinalysis to screen for illegal drug use prior to appointment.
- ✓Applicants who refuse to be tested will be denied employment with VA.
- ✓Selective Service Registration is required for males born after 12/31/1959.
- ✓Must be proficient in written and spoken English.
- ✓Subject to background/security investigation.
- ✓Selected applicants will be required to complete an online onboarding process.
- ✓Acceptable form(s) of identification will be required to complete pre-employment requirements (https://www.uscis.gov/i-9-central/form-i-9-acceptable-documents).
- ✓Effective May 7, 2025, driver's licenses or state-issued identification cards that are not REAL ID compliant cannot be utilized as an acceptable form of identification for employment.
- ✓Must pass pre-employment physical examination.
- ✓Participation in the seasonal influenza vaccination program is a requirement for all Department of Veterans Affairs Health Care Personnel (HCP).
- ✓Complete all application requirements detailed in the "Required Documents" section of this announcement.
- ✓As a condition of employment for accepting this position, you will be required to serve a 1 or 2-year trial period during which we will evaluate your fitness and whether your continued employment advances the public interest.
Personality Fit
This role is commonly a great fit for these MBTI types:
Job ID: 462b2cfb-fb76-4d04-a481-02a95becc66f
Posted via USAJobs