Medical Records Administrator

Full Job Description

This position is located in the Health Information Management (HIM) Section of Health Information Management Service at the New Mexico VA Medical Center in Albuquerque, New Mexico.

Medical Records Administrators (MRAs) in VHA perform or supervise work concerned with the management of a health record program or the provision of services related to medical record administration/health information services.

Applicants pending the completion of educational or certification/licensure requirements may be referred and tentatively selected but may not be hired until all requirements are met.Basic Requirements: United States Citizenship: Candidates must be a citizen of the United States.

Non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy. Education or Experience: Experience.

Three years of creditable experience in the field of medical records that included the preparation, maintenance, and management of health records and health information systems demonstrating a knowledge of medical terminology, medical records procedures, medical coding, or medical, administrative, and legal requirements of health care delivery systems.

OR, Education. Successful completion of a bachelor's degree or higher from an accredited college or university [recognized by the U.S.

Department of Education, with a major field of study in health information management, or a related degree with a minimum of 24 semester hours in health information management or health information technology.

OR, Experience/Education Combination. Equivalent combinations of creditable experience and education that equals 100 percent may be used to meet basic requirements.

For example, two years above high school from an accredited college or university, with 12 semester hours in health information technology/health information management, plus one year and six months of creditable experience that included the preparation, maintenance, and management of health records and health information systems meets an equivalent combination.

Certification. Employees at this level must have a HIM Certification through AHIMA. Higher-level health information management certification is limited to certification obtained through AHIMA.

To be acceptable for qualifications, the specific certification must represent a comprehensive competency in the occupation.

Certification titles may change and certifications that meet the definition of HIM certification may be added/removed by the above certifying body; however, current HIM certifications include Registered Health Information Technician (RHIT) and Registered Health Information Administrator (RHIA).

English Language Proficiency. MRAs must be proficient in spoken and written English.

May qualify based on being covered by the Grandfathering Provision as described in the VA Qualification Standard for this occupation (only applicable to current VHA employees who are in this occupation and meet the criteria).Grandfathering Provision.

All persons employed in VHA as an MRA are considered to have met all qualification requirements for the title, series, and grade held, including positive education, and registration and/or certification that are part of the basic requirements of the occupation.

For employees who do not meet all the basic requirements in this standard, but who met the qualifications applicable to the position at the time they were appointed, the following provisions apply: Such employees may be reassigned, promoted up to, and including, the full performance (journeyman) level, or changed to lower grade within the occupation, but may not be promoted beyond the [journeyman] level or placed in supervisory or managerial positions.

Employees who were appointed on a temporary basis, prior to the effective date of the qualification standard, may not have their temporary appointment extended or be reappointed on a temporary or permanent basis until they fully meet the basic requirements of the standard.

Employees initially grandfathered into this occupation who subsequently obtain additional education and/or licensure/[registration/certification, and meet all the basic requirements of this qualification standard, must maintain the required credentials as a condition of employment in the occupation.

MRAs who are converted to title 38 hybrid status under this provision and subsequently leave the occupation lose protected status and must meet the full VA qualification standard requirements in effect at the time of reentry, as a medical records administrator.

Grade Requirements:Grade Determinations, GS-13. In addition to the basic requirements for employment, the following criteria must be met when determining the grade of candidates. Experience.

One year of creditable experience equivalent to the next lower grade level that demonstrates the KSAs described at that level.

Demonstrated Knowledge, Skills, and Abilities: In addition to the experience, the candidate must demonstrate all of the following KSAs:.

Ability to determine and evaluate compliance with legal, ethical and regulatory guidelines and accrediting bodies, as they apply to health information management.

Ability to provide sound, technical guidance to staff at various levels about major program, legal, or procedural changes related to health information management.

Skill in revising facility policies and procedures to improve health information management services and to evaluate, modify, and/or adapt new methods to meet regulatory requirements.

Skill in analyzing complex data, interpreting and trending results for effective management of the HIM program.

Skill in management/administration, which includes program planning, coordination, interpretation, supervision, consultation, negotiation, problem solving, and monitoring of HIM processes.

Ability to delegate authority, evaluate and oversee people and programs, accomplish program goals, and adapt to changing priorities.

Reference: VA Handbook 5005/130 Part II Appendix G33 Effective Date May 28, 2020.Physical Requirements: No special physical demands such as above average ability, dexterity, or strength are required to perform the work.

The nature of the work is administrative in an office type setting working on a computer.

Lifting and carrying (under 15 lbs.) would be occasional but only in direct support of the administrative duties required by the nature of the work. Major Duties:

Serves as Chief of Health Information Management (CHIM) with full program responsibility for all facets of the Health Information Management (HIM) program and processes.

Creates and monitors systems to ensure accurate, timely, and complete health records, in accordance with VHA policy and TJC health information protocols.

Measures ongoing intradepartmental performance by establishing priorities, collecting data, monitoring and reporting outcomes, using valid and reliable techniques to analyze trends and variation, and taking appropriate action based on findings.

Develops policies, processes, and procedures that address all VA, Federal, regulatory, and accrediting requirements for HIM.

Evaluates health records program and independently determines the nature and extent of problem areas. Develops recommendations and solutions for program improvement.

Develops and implements innovative solutions to correct technical, complex problems. Must provide detailed technical expertise in health records science and other very technical aspects of HIM.

Must assure that all health information that is coded and abstracted meets the requirements of the VA and/or TJC and is consistent with professional health records standards.

Completes internal quality assurance reviews to ensure employee performance and that work meets quality and quantity standards.

Establishes monitors to ensure the timeliness of health record entries and reports findings with subsequent trending of data.

Provides management officials with health record review results and trends on an ongoing basis.

The incumbent is a key member of the Quality Improvement (QI) team, works closely with QI personnel, and is responsible for assuring that the facility is compliant with all TJC standards regarding health information.

Responsible for assuring that all patients have a complete, accurate, and timely record of their health care at the facility. Responsible for leading the automation of all health information systems.

The incumbent also must support the information security program and manage much of the patient information database within VistA.

Incumbent conducts training programs in various areas health information management, such as medical terminology, health record documentation, release of information, medical coding, clinical documentation improvement, and health information exchange.

Responsible for coordinating health information training for medical school students and residents to achieve conformance with prescribed standards.

Participates in facility or VISN research activities related to health information and electronic health record (EHR) issues.

Provides full support to accomplish VHA Central Office HIM Program Office strategic goals and objectives.

Assists with writing practice briefs, fact sheets, standard operating procedures, and other types of guidance documents as requested.

Incumbent is responsible for directing the operations of all personnel working within the HIM program and is regularly involved in labor relations and budget management.

Participates in the recruitment, interview, selection, and orientation process of all HIM positions.

Is designated as facility subject matter expert for the recruitment, interview, and selection of GS-0675 Medical Records Technician (MRT) and GS-0675 Medical Records Administrator (MRA) positions organizationally aligned within HIM and in departments outside of HIM.

Participates in selection, approval, and disapproval of candidates in the GS-0675 and GS-0669 occupational series throughout the VA medical facility.

Performs the administrative and personnel management functions relative to staff supervised. Establishes guidelines and performance expectations for staff. Resolves informal complaints and grievances.

Develops work improvement plans, recommending personnel actions as necessary. Provides advice and counsel to workers related to work and administrative matters. Reviews and approves leave requests.

Performs these duties as the facility expert but does not involve substantial line responsibility for establishing and implementing overall clinical policies.

Incumbent is directly responsible to the Chief, Health Administration Services who gives general objectives.

Incumbent exercises independent judgment in carrying out duties and responsibilities and has complete authority to plan, design and direct the HIM program; recommendations and/or technical decisions made by employee are not reviewed.

Must be able to interpret federal and state statutes, legislation and regulations in order to satisfy regulatory requirements3 Work Schedule: Monday thru Friday, 8:00am to 4:30pm Telework: Not Available Virtual: This is not a virtual position.

Functional Statement #: 000000 Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized