Medical Records Administration Specialist

Summary

This position is located in the Health Information Management (HIM) Section of the Medical Administration Service at the Oklahoma City VA Healthcare System. The Medical Records Administration Specialist manages, analyzes, and oversees health records and information, performs data mining, reporting, workflow analysis, quality improvement, and health record reviews, provides training, and presents findings to leadership and supports operational decisions.

Duties

Serves as a technical specialist and subject matter expert in health information management (HIM), providing advice and guidance on documentation requirements for coding, liability issues, advance directives, informed consent, scanning, speech recognition, release of information, state reporting, record control, confidentiality, and regulatory requirements. Conducts research and coordinates projects and studies involving health record systems. Determines the scope of studies, develops action plans and study tools, compiles and analyzes data, summarizes findings, makes recommendations, and prepares management reports. Analyzes HIM processes, workflows, and record review systems; identifies best practices and opportunities for improvement; and recommends and implements changes to improve productivity, data quality, performance, and turnaround times. Assists in developing, revising, and maintaining health information policies and procedures to incorporate new approaches while ensuring compliance with VHA directives, federal regulations, The Joint Commission standards, and medico-legal requirements. Conducts quantitative and qualitative health record reviews and quality assurance studies to ensure documentation is accurate, timely, complete, and supports patient care, data collection, research, coding, reimbursement, and legal requirements. Compiles, reviews, abstracts, retrieves, analyzes, and interprets medical, legal, clinical, diagnostic, procedural, workload, and statistical data for local, VISN, VHA, research, and special-study needs. Assures the accuracy and timeliness of patient service charge and workload capture in accordance with applicable laws and regulations. Reviews clinical documentation, encounter data, registration information, and charge records to identify and resolve errors, missing charges, suspended charges, and encounters requiring additional action. Serves on the local Revenue Cycle/Charge Services Team and collaborates with clinical, ancillary, administrative, informatics, revenue, finance, and other departments to ensure HCPCS/CPT charge items and associated documentation accurately reflect the service, date, and rendering provider. Coordinates CPT/HCPCS coding and Charge Description Master updates; supports validation of clinical and encounter data; audits reports such as Charges out of Bounds, Suspended Charges, and General Ledger reports; and facilitates correction of documentation and registration issues affecting encounter accuracy. Serves as a liaison for electronic health record (EHR) and automated clinical applications. Analyzes information flow, tests and verifies HIM software and patches, coordinates local testing with developers, troubleshoots functional issues, submits work orders or Remedy tickets, and provides feedback regarding system modifications and enhancements. Provides technical assistance for HIM software and computer applications, including coding, release of information, dictation, medical speech recognition, electronic forms, templates, and other EHR functions. Reviews requests for new or revised templates and forms and assists with implementation. Serves as a point of contact for health record corrections, including retracting erroneous notes, re-titling notes, assigning or removing notes from consult requests, and reassigning, rescinding, or removing incorrectly entered or uploaded documents. Collaborates with physicians, nurses, clinical providers, Clinical Applications Coordinators, and other staff to resolve incomplete, inconsistent, or improperly identified documentation and provides guidance on capturing required medical information. Provides training and education to HIM, clinical, and administrative staff on health information management, documentation, coding, EHR functionality, privacy, release of information, revenue cycle processes, and emerging technologies. Assists the Chief, Health Information Management, and HIM leadership in establishing program goals, objectives, quality improvement initiatives, presentations, audits, performance monitors, and short- and long-range plans. Participates in facility, VISN, and national committees and subcommittees requiring HIM expertise and collaborates with National Program Offices, the Office of Finance, Managerial Cost Accounting Office, VAMC, VISN, CPAC, and National Charge Services Teams, as applicable. Work Schedule: Full-time, Monday - Friday, 8:00 AM - 4:30 PM Telework: Not Available Virtual: This is not a virtual position. Functional Statement #: 60228-0, 60225-0, 60226-0, 60227-0

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 REQUIREMENTS. 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. 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. NOTE. See paragraph 2a for a detailed definition of Coding Certification. OR, (2) HIM Certification through AHIMA. NOTE. See paragraph 2d for a detailed definition of HIM Certification. OR, (3) Health Data Analyst Certification through AHIMA. NOTE. See paragraph 2c for a detailed definition of Health Data Analyst Certification. Grandfathering Provision. 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). Grade Determinations. In addition to the basic requirements for employment, the following criteria must be met when determining the grade of candidates. Medical Records Administration Specialist, GS-5. None beyond basic requirements. Medical Records Administration Specialist, GS-7 (a) Experience. In addition to the basic requirements, one year of creditable experience equivalent to the next lower grade level. OR, (b) Education. (Advanced Entry-Level Placement). Applicants who meet the GS-5 grade level may be