Medical Records Administrator (Chief (CHIM))

Full Job Description

This position is located in the Health Information Management (HIM) Section of the Medical Administration Service (MAS) at the Martinsburg VA Medical Center.

Medical Records Administrators (RAs) 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.

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. 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.

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

One year of creditable experience equivalent to the GS-12 grade level that demonstrates the KSAs described at that level.

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

Skill in evaluating, developing and implementing new policies , procedures, and programs.

Ability to provide program oversight, including advisory and technical expertise on a range of health information management practices and guidelines to staff at various levels.

Ability to develop and conduct training on health information management programs, policies, procedures, and performance improvement activities.

Ability to effectively procure and manage HIM resources (i.e. space, staffing, education, budget, etc.).

Ability to provide the full range of supervisory duties to include assignment 12 of work; completing performance evaluations; selection of staff; and recommendation of awards, advancements, and disciplinary actions.

Customer service skills necessary to effectively communicate (written and verbal) and interact with all levels of hospital personnel, physicians, patients, and outside agencies.

Ability to deal effectively with sensitive and/or complex situations AND (b) Certification. Employees at this level must have a HIM Certification. NOTE.

See paragraph 2d of this appendix for detailed definitions of HIM Certification.

AND Demonstrated Knowledge, Skills, and Abilities 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: 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-13 Physical Requirements: See VA Directive and Handbook 5019. Major Duties:

Functions Responsible for complex, multi-disciplinary processes and functions, which may include multiple contacts, academic affiliations, and highly sophisticated regulatory requirements.

Must ensure the HIM program complies with national HIM policies and procedures and meets or exceed national HIM performance metrics.

Responsible for the administrative management of health records, which includes planning, managing, advising, and directing the HIM program in accordance with applicable Federal laws, facility by-laws, VHA policy, The Joint Commission (TJC) standards, the Commission on Accreditation of Rehabilitation Facilities (CARF), and other regulatory and accrediting agency standards.

Responsible for all aspects of health records management for the facility ensuring maintenance of complete, accurate, timely, clinically pertinent, and readily accessible patient health records, which contain sufficient recorded information to serve as a basis to plan patient care, support diagnoses, warrant treatment, measure outcomes, support education, research and facilitate performance improvement processes and legal requirements.

Develops policies, processes, and procedures that address all VHA, Federal, regulatory, and accrediting requirements for HIM Provides detailed technical expertise in health records science and other very technical aspect of HIM.

Maintains all health information entered into local databases and assures timely transmission of that data into all VA centralized databases-most frequently those maintained at the Austin Data Processing Center.

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

Serves as a key advisor to the Chief of Staff, Executive Management, clinical and administrative staff is responsible for providing technical guidance on health information issues such as documentation requirements, encounter completion, industry and federal regulatory compliance, advance directives, informed consent, clinical documentation integrity, medical coding, release of information, transcription/speech recognition, scanning and indexing health information exchange.

Conducts training on various topics related to HIM, such as medical terminology, health record documentation, release of information, medico-legal matters, speech recognition/transcription, scanning and indexing, medical coding, clinical documentation integrity, and health information exchange.

Performs administrative and personnel management functions relative to staff supervised. Responsible for maintenance and evaluation of health records and assuring legal requirements for care are met.

Develop and coordinate internal review systems to assure that both clinical and administrative activities comply with agency and accrediting and regulatory requirements.

Work Schedule: Monday-Friday; 8:00AM-4:30PM Functional Statement #: 26554-F Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized