Medical Records Administrator, (Assistant Chief Health Information Management (ACHIM))

Full Job Description

This position is located in the Health Information Management (HIM) Section of the Health Administration Service of the Central Alabama Veterans' Health Care System.

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

English Language Proficiency: MRAs must be proficient in spoken and written English. See 38 U.S.C. § 7403(f). Experience or Education: 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. Persons hired or reassigned to MRA positions in the GS-0669 series in VHA must meet one of the following: Coding Certification through AHIMA or AAPC. OR HIM Certification through AHIMA.

OR Health Data Analyst Certification through AHIMA. GS-11 Grade Determinations: Experience.

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

Education equivalent to three full years of progressively higher-level graduate education or a Ph.D., or equivalent doctoral degree, from an accredited university or college in the field of health information.

AND Certification. Employees at this level must have a HIM Certification. AND Demonstrated Knowledges, Skills, and Abilities. 1.

Skill in performance and process improvement techniques to develop and implement new or improved solutions in health information management. 2.

Ability to advise management and staff at various levels regarding health record documentation requirements and health information management practices based on current industry standards, policies, statutes, laws, and regulations.

3. Ability to plan, justify, develop, evaluate, assess, monitor, and advise on current health information management processes and recommend changes in policies or procedures. 4.

Ability to determine and evaluate compliance with legal, ethical, and regulatory guidelines and accrediting bodies as they apply to health information management. 5.

Ability to plan, justify, develop, evaluate, assess, monitor and/or advise on current HIM processes and recommend changes in policies or procedures. 6.

Ability to successfully apply principles and techniques of sound resource management (i.e., staffing, space, contracts, equipment). 7.

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

Reference: For more information on this qualification standard, please visit https://www.va.gov/ohrm/QualificationStandards/. The full performance level of this vacancy is GS-11.

The actual grade at which an applicant may be selected for this vacancy is GS-11. Physical Requirements: See VA Directive and Handbook 5019 Major Duties:

Duties: Assists the Chief HIM (CHIM) in establishing policies, responsibilities, and requirements for health information management (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 Veteran's health records.

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

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

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

Provides consultation and management support to the above units to ensure smooth operation of a customer-focused, forward-thinking and efficiently managed department.

Functions as Acting Chief of the Section and is responsible for overall management of the Sections' program and function.

Aids with the overall effective administration and planning of the HIM program throughout all areas of the facility in order to give maximum support to the staff in the treatment of patients.

Performs documentation corrections: documentation errors consist of retracting erroneous notes, re-titling notes, assigning notes to or removing from consult requests.

Analyzes workflow to determine potential problem areas and makes recommendations to correct these areas and improve coordination between the various units.

Obtains, organizes, files, and retrieves reports, correspondence, and financial data for use in preparing status reports, briefings, and presentations.

Identifies and recommends ways of eliminating, combining, simplifying, or improving procedures and processes.

Establishes criteria and provides education when dealing directly with physicians, nurses and other clinical providers requesting them to complete or adjust pertinent parts of the health records, which are found to be inconsistent or incomplete upon analysis.

Selects, compiles and trends medical, surgical and statistical data from numerous components of the health record.

Retrieves diagnostic and statistical data for various reports required locally or by Central Office.

Prepares training materials and participates in orientation and instructional activities as required.

Advises management and hospital staff members on policies, procedures and adequacy of record content, and on training and teaching of clerical personnel in health record functions.

Participates in various health record review activities.

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

Assists with planning, developing, directing and evaluating health information and other functions. Demonstrates skill in budgeting, contracting, procurement and property management.

Designs and implements a program to measure compliance with documentation standards for all areas of the medical center including: inpatient, outpatient, home health, long term care, behavioral health, rehabilitation and fee basis.

Aids in a variety of projects and is responsible for screening, abstracting and tallying data from records and computer-generated reports.

Serve as a consultant to provide guidance and advise researchers on methods for gathering data.

Assists in selected miscellaneous retrospective medical record review/data abstraction projects to support medical center Quality Management data collection activities.

Advises staff in problem areas about quantitative and qualitative analysis of health records and determines acceptability of content.

Consults with physicians and other clinicians regarding health record deficiencies as appropriate.

Assists with the retrieval, review, analysis and reporting of HIM performance monitors and other medical record review topics. Work Schedule: Monday - Friday 8:00a.m. - 4:30p.m.

Work schedule subject to change based on agency needs. Telework: Ad hoc Virtual: This is not a virtual position.

Functional Statement #: 619-55278F Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized