Medical Records Administrator (Chief Health Information Management)

Full Job Description

A RECRUITMENT/RELOCATION INCENTIVE MAY BE AUTHORIZED This assignment is the Chief Health Information Management (CHIM), which is the highest-level professional position at the facility with responsibility to manage and direct the health information management program.

The CHIM has full program management and supervisory responsibility to direct professional Medical Records Administrators, technical Medical Records Technicians, and other support staff in health information management.

To qualify for this position, applicants must meet all requirements within 30 days of the closing date of this announcement. BASIC REQUIREMENTS.

United States 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: 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. HIM Certification through AHIMA.

Health Data Analyst Certification through AHIMA. NOTE: HIMs Certification is required for all positions above the full performance level.

Loss of Credential: Following initial certification, credentials must be maintained through rigorous continuing education, ensuring the highest level of competency for employers and patients.

An employee in this occupation who fails to maintain the required certification must be removed from the occupation which may result in termination of employment.

At the discretion of the appointing official, an employee may be reassigned to another occupation for which he/she qualifies, if a placement opportunity exists.

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

Medical Records Administrator (Chief (CHIM)), GS-13 Experience: One year of creditable experience equivalent to the next lower grade level that demonstrates the KSAs described at that level.

AND Certification: Employees at this level must have a HIM Certification. NOTE. 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).

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 Assignments: This assignment is the Chief Health Information Management (CHIM), which is the highest-level professional position at the facility with responsibility for the management and direction of the health information management program.

This assignment is only for the CHIM 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", with full program management and supervisory responsibility to direct professional MRAs, technical MRTs, and other support staff in health information management.

CHIMs in this assignment provide technical advice, planning, and evaluation about health information management issues impacting the overall program on a regular and recurring basis.

Multi-division, integrated health care systems under the leadership of a single director are considered to be a single facility with one CHIM.

A position with program responsibility over less than a single health care system does not have full program responsibility for the health information management program.

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

They oversee development, 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.

The CHIM monitors HIM performance through dashboards, productivity standards, and benchmarking.

They participate in establishing and implementing strategic facility and HIM Department goals and controlling program activities and cost, budgeting, procurement, and property management, to achieve goals and improve processes.

The CHIM monitors and manages HIM workflow to ensure program objectives are met.

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-13.

Physical Requirements: Light lifting and carrying (under 15 pounds); reaching above shoulder; use of fingers; both hands required; and the ability to see to read material. Major Duties:

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

Ensure HIM program meets and exceed national HIM policies, procedures, and performance metrics.

Responsible for the administrative management of health records; plan, manage, advise, and direct the health information 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.

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

Responsible for all facets 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.

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

Clinical Support Role Be a key advisor to the Chief of Staff, Executive Management, and clinicians.

Provide technical guidance on health information issues such as documentation requirements, liability issues, advance directives, informed consent, release of information, transcription/speech recognition, and health information exchange.

Recommend improvements in health record documentation used to provide patient care, to optimize VERA workload, third party reimbursement, and to manage resources.

Complete internal quality assurance reviews to ensure employee performance meets quality and quantity standards.

Provide management officials with health records review results and trends on an ongoing basis. Monitor and report delinquent records by number, type of deficiencies, and responsible provider.

Administration and Strategic Planning Has full operational responsibility to set and carry out the strategic direction, mission, and vision for VAPSHCS' Health Information Management Services.

Coordinate individual and group activities to accomplish overall VA, VISN, and Puget Sound goals.

Coordinate plans with needs of various VA strategic health groups, provide subject matter expertise, advice, assistance, and guidance in response to questions posed by the Service Line Leaders and other System staff on health information management policy and program needs/issues at the local, VISN and national levels.

Contract Management Administer the Transcription and Coding Contract(s); prepare and monitor budget for contract.

Ensure outsourced coding personnel understand and agree to adhere to VA and Puget Sound's HIM compliance program and complete yearly required confidentiality, privacy, and security training.

Ensure quality controls are in place for any scope of work conducted by contractors.

Collaborate with Service Lines to improve documentation, coding, and reporting for workload, billing, Fee Basis, and other emerging initiatives.

Auditing and Training Develop and coordinate training programs in various areas of health information management, such as medical terminology, health record documentation, release of information, medico-legal matters, speech recognition/transcription, scanning, medical coding, clinical documentation improvement, and health information exchange.

Responsible for establishing formal affiliation with university programs in health information and precepting students from such programs.

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

Personnel Management Responsible for overall personnel management for staff in the assigned units and determines staffing patterns and reassigns personnel to meet changing conditions.

Make selections for immediate subordinate positions. Review and approve selections made by subordinate supervisors.

Community Service Develop and maintain affiliation agreements with AHIMA recognized schools and programs for health information management and technology.

Provide internship and directed student learning opportunities for HIM students and newly graduated professionals; actively support other training such as Veteran Work-Study, Veteran Readjustment Employees, and numerous programs with local learning institutions.

Work Schedule: Mon - Fri, 8:00am to 4:30pm Telework: Ad-hoc Virtual: This is not a virtual position Functional Statement #: 000000 Relocation/Recruitment Incentive: May be authorized Permanent Change of Station (PCS): Not authorized