Chief Medical Records Administrator

The position is located within the VA Medical Center, Washington, D.C., Business Office. It provides comprehensive primary and specialty services in medicine, surgery, neurology, and psychiatry using a primary care model. The position is organizationally aligned under the Health Information Management Section(HIMS) and is expected to work closely with all members of the health care team, Medical Center's Administration, Site Managers Offices, Business Office and VAMC Executive Leadership.

Qualifications:

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 REQIREMENTS

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:

1. Coding Certification through AHIMA or AAPC.

OR

2. HIM Certification through AHIMA.

OR

3. Health Data Analyst Certification through AHIMA.

NOTE. HIMs Certification is required for all positions above the full performance level.


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


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

Medical Records Administrator (Chief (CHIM)), GS-13

Experience:
One year of creditable experience equivalent to the next lower grade (GS-12) level that demonstrates the KSAs described at that level.

Example of GS-12 Experience/KSA's:
- Ability to determining and evaluating 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 of work, completing performance evaluations, selection of staff, and recommendation of awards, advancements, and disciplinary actions.
- Communicate effectively (both written and verbal) and interact with all levels of hospital personnel, physicians, patients, and external agencies.
- Ability to deal effectively with sensitive and/or complex situations.

AND

Certification:
Employees at this level must have a HIM Certification.

AND

Demonstrated GS-13 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 visithttps://www.va.gov/ohrm/QualificationStandards/.

The full performance level of this vacancy is GS-13.

Physical Requirements: See VA Directive and Handbook 5019.

Responsibilities:

The Chief Medical Records Administrator is a Registered Health Information Administrator who is charged with full responsibility, both technical and administrative, for the daily operation of the Health Information Management Section, which consists of all functions of medical record activities related to coding, analyzing, and release of information, transcription, file room, and scanning programs.

Provides expertise, guidance, and direction and has responsibilities relative to providing supervision, administrative support, coordination, and technical assistance in the planning, development, and maintenance of an effective, comprehensive, and integrated HIM Program at this Medical Center.

FUNCTIONS:

1. Provides technical and managerial expertise relative to health information management. This includes recommendations regarding organizational structure, workflow, section policy, interpretation of section objectives, and methods of staffing within the section. Implements recommendations and exercises immediate supervisory authority over the Coding Unit, File/ Scanning unit, and Release of Information Unit. Has knowledge of statistics to assess patient workload and establish quality controls.
2. Evaluates Patient Treatment File PTF data validation program to include a qualitative review and evaluation of the clinical as well as administrative information reported into the PTF system, with analysis and recommendations for corrective action. Responsible for the timely and complete submission of all quarterly census patients and for the PTF abstracts, which have a monthly close-out date with an annual hard close-out date for the fiscal year to the Austin Automation Center AAC National Patient Care Database NPCD.
3. Advises Medical Record Technicians MRT in problem areas about quantitative and qualitative analysis of medical records and determines the acceptability of content. Consults with physicians and other clinicians regarding record deficiencies as appropriate.
4. Coordinates and updates the Quality Management program for HIMS. Joint Commission and VA standards require a quality management program, which includes medical record audits based on input from the Medical Records Committee, quality improvement staff, and medical staff. Audits will consist of review files. Develops and maintains collaborative relationships with Physicians, Service Chiefs, and other medical center staff at all organizational levels.
5. Additionally, is responsible for determining the need for and extent of training personnel outside HIMS regarding the medical records and its format. May be required to develop training materials and continuing education programs. Training programs developed and conducted by employees may include medical terminology, Evaluation and Management Code assignment, medical record documentation requirements, Release of Information, Privacy Act, and HIPAA instructions. Assistance is also provided in formal and informal service training and orientation of house staff, as well as other members of the health care team, regarding medical record functions and quality content.
6. Responsible for assisting physicians and other health professionals in obtaining medical record information to be used in research projects. Advises on what material is available, how it may be obtained, and the uses that can be made of the information while protecting the confidentiality of the record.
7. Provides technical guidance to the unit supervisors and lead clerks while providing support to each unit in the absence of the section supervisor. Provides expertise in subpoenas, court orders, advance directives, Privacy Act, Freedom of Information Act, and general release of information, as well as other medical and legal issues.
8. Work is of an analytical, evaluative, and creative nature, and the incumbent is responsible for keeping abreast of changes that are constantly being made in the health information field as well as allied medical fields and applying the information and knowledge gathered to the operations of the hospital.

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

Telework: Not Available

Virtual: This is NOT a virtual position.

Functional Statement #: 688-25115-F

Relocation/Recruitment Incentives: May be Authorized

Salary : $121,785