Medical Records Administrator (Assistant Chief (ACHIM))

Full Job Description

VHA Medical Records Administrators (MRAs) manage, preserve, analyze, and oversee health records and information services.

They develop policies, ensure proper use of health information, and provide expert guidance on health information management.

The incumbent offers technical and administrative leadership, supports policy development, and serves as acting Chief of Health Information Management (CHIM) in their absence.

Basic Requirements: United States Citizenship: Non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy. Citizenship.

[Candidates must be a citizen] of the United States. Non-citizens may be appointed when it is not possible to recruit qualified candidates in accordance with 38 U.S.C. § 7407(a).

Education or Experience: (1) 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, (2) 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, (3) 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. Health Information Management (HIM) Certification.

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).

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).

English Language Proficiency. MRAs must be proficient in spoken and written English. See 38 U.S.C. § 7403(f).

Grade Determinations: GS-12 Experience: Must have one year of creditable experience equivalent to the next lower grade level that demonstrates all the KSAs described at that level.

AND Demonstrated knowledge, skills, and abilities: i.

Skill in managing various projects and processes, which includes the ability to develop new or improved solutions to complex technical problems in health information management. ii.

Ability to advise management and staff on a wide range of health information management practices based on current industry standards, policies, statutes, laws, and regulations. iii.

Ability to plan, justify, develop, evaluate, assess, monitor, and/or advise on current health information management processes, and recommend changes in policies or procedures. iv.

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

Ability to successfully apply principles and techniques of sound resource management [(i.e., staffing, space, contracts, equipment). vi.

Ability to provide the full range of supervisory duties to include assignment of work, completing performance evaluations, selection of staff, and recommendation of awards, advancements, and disciplinary actions.

Creditable Experience. Experience is only creditable if it is in health information management and is directly related to the position to be filled.

To be creditable, the candidate's experience must have demonstrated the use of knowledge, skills, and abilities associated with current practice.

Experience satisfying this requirement must be active practice, which is paid/non-paid employment as an MRT/MRA or related field such as medical coding, qualitative and quantitative health record analysis, Health Insurance Portability & Accountability Act privacy and release of information, or preparation, maintenance, and management of health records.

Assignments.

This assignment serves as the Assistant Chief in VA Medical Centers for all categories (1a, 1b, and 1c) within the complexity level 1 as designated in the VHA, "2014 Facility Complexity Level Model".

The ACHIM assists the CHIM in establishing policies, responsibilities, and requirements for HIM related matters, such as health record documentation, coding and clinical documentation improvement, records management, release of information, file room/scanning, transcription and medical speech recognition, as well as the overall management of health information and Veterans' health records.

They assist the CHIM in identifying and setting short-range and long-range goals, program objectives, and tasks to meet the mission and vision of the medical center.

The ACHIM monitors and manages HIM workflow to ensure the program objectives are met. The ACHIM assists with planning, developing, directing, and evaluating health information and other functions.

They oversee implementation and adherence to HIM industry standards, policies, procedures, laws, regulations, and accrediting bodies.

They ensure the facility is in compliance with applicable standards by completing HIM audits, developing healthcare data reports, and statistical information, for timely and accurate reporting.

They establish, implement, and monitor HIM performance through metrics, productivity measures, benchmarking, and other applicable tools.

The ACHIM ensures quality and efficiency for all areas and processes of the HIM department.

Preferred Experience: Experience with coding, billing, revenue, utilization review, and auditing workflows Hold a AAPC/AHIMA specialty coding certification in one or more following areas and/or have creditable experience as a seasoned coder: Inpatient (Acute Care, Domiciliary, CLC, SNF) Coding Outpatient Coding Surgery Coding Prosthetics/DME Coding Inpatient Appointments/Professional Fees Coding Experience with Cerner EHRM Experience with 3M Coding and Reimbursement Systems Experience with standardized mortality ratios (SMR), including acute care and ICU 30-day and in-hospital mortality measures Reference: For more information on this qualification standard, please visit https://www.va.gov/ohrm/QualificationStandards/.Medical Records Administrator Qualification Standard Physical Requirements: You will be asked to participate in a pre-employment examination or evaluation as part of the pre-employment process for this position.

Questions about physical demands or environmental factors may be addressed at the time of evaluation or examination. Major Duties:

The position requires the incumbent to physically report for work to the Des Moines, IA VAMC.

Major duties include, but are not limited to: Serves as full assistant to the Chief of Health Information Management (CHIM), providing expertise, guidance, and supervision to support the planning, development, and maintenance of a comprehensive, integrated HIM Program.

Assists the CHIM in directing, organizing, and controlling HIM department activities, and serves as Acting CHIM in the CHIM's absence.

Shares responsibility with the CHIM for collecting and processing data for reports, surveys, and research projects; preparing recommendations for upper management on department needs and long-term goals; and developing and updating policies, standard operating procedures, and training guides.

Assists physicians and health professionals in obtaining health record information for research, advising on data availability and use while protecting record confidentiality.

Supports retrospective health record review and data abstraction projects to advance Quality Management activities.

Conducts ongoing audits across all areas of responsibility to ensure accurate and timely data processing.

Reviews employee work for quality, accuracy, and timeliness, providing constructive feedback and developing performance improvement plans as needed.

Develops performance standards, conducts evaluations and competency assessments, and carries out established personnel functions including interviewing, selection, training, leave approval, work scheduling, and disciplinary actions.

Implements EEO provisions to ensure fair treatment for all employees. Coordinates monthly staff meetings and prepares accurate minutes.

Serves as subject matter expert on GS-0675 Medical Records Technician and GS-0669 Medical Records Administrator qualification standards.

Provides technical guidance to HIM supervisors and leads, supports section units in the absence of supervisors, and provides expertise in subpoenas, court orders, advance directives, release of information, and other medico-legal issues.

Prepares training materials and participates in orientation and instructional activities. Advises management and staff on policies, procedures, and health record content adequacy.

Develops and conducts training and continuing education programs covering medical terminology, documentation requirements, coding, clinical documentation integrity, transcription/speech recognition, scanning and indexing, release of information, and HIPAA/Privacy Act requirements.

Provides orientation and training to house staff and other health care team members on health record functions and quality.

Participates in facility, VISN, and national committees that require HIM subject-matter expertise. Prepares and presents reports and data to committees.

Develops and updates policies pertaining to committee functions, health record reviews, and HIM activities.

Ensures health record review activities comply with VHA handbooks, directives, TJC standards, CARF, Behavioral Health, and OIG requirements.

Advises committees, management, and staff on health record documentation, health information services, and EHR practices based on current policies and industry standards.

Assists the CHIM in identifying short- and long-range goals and program objectives aligned with the medical center's mission and vision.

Supports planning, directing, and evaluating HIM functions, including budgeting, contracting, procurement, and property management.

Ensures all activities comply with VA/VHA regulations, Medical Center Memoranda, and accreditation requirements, including TJC and CARF standards.

Maintains current knowledge of developments in the health information field and applies that knowledge to hospital operations.

Work Schedule: Monday thru Friday 7:30 am -4:00 pm 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