Medical Records Administrator (Assistant Chief (ACHIM))

Summary

This position serves as the Assistant Chief of Health Information Management who assists the Chief HIM in establishing policies, responsibilities, and requirements for health information management 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 Veterans' health records.

Duties

Major duties include but not limited to: Incumbent is charged with full responsibility, both technical and administrative, for the daily operation of the HIM department which consists of all functions of health record activities related to coding, health record documentation analysis, transcription/speech recognition, release of information, file room/scanning programs, and health information exchange. Is a full assistant to the Chief of Health Information Management (CHIM). 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. This position assists the CHIM in the planning, directing, policy making, organizing and controlling the activities of this department and serves as acting CHIM in the absence of the CHIM. The incumbent shares responsibility with the CHIM for collecting and processing data for various reports, surveys, and research projects; for preparing reports and recommendations for review and consideration by the Chief, Health Administration Service and upper management concerning the immediate needs as well as the long range goals of the department; for recommending equipment and staffing needs; and for preparing and keeping current procedures and operation manuals. Responsible for assisting physicians and other health professionals in obtaining health 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. The incumbent aids in a variety of projects and is responsible for screening, abstracting and tallying data from records and computer-generated reports. Provides effective audits and monitors for all areas of responsibility, assuring that accurate and timely data is processed by all employees. Reviews work accomplished and assesses quality, quantity, accuracy and timeliness of work produced by each employee. Develops and conducts competency assessments. Responsible for carrying out established personnel functions and practices. Keeps employees informed about important aspects of personnel management programs. Formulates and initiates performance standards. Interviews prospective employees, recommends selection, and carries out training and development of assignments, awards or disciplinary action. Approves leave and establishes work schedules. Provides administrative support to other HIM Supervisors/Leads by aiding in the selection, training and evaluation of section employees. 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 the area of subpoenas, court orders, advance directives, and general release of information, as well as other medico-legal issues. The incumbent prepares training materials and participates in orientation and instructional activities as required. Incumbent 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. Incumbent participates in various health record review activities. May be required to develop training materials and continuing education programs. Training programs developed and conducted by employee may include medical terminology, health 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. Ensures that health record review activities are consistent with the requirements established by VA handbooks and directives and are in compliance with TJC standards and Scoring Guidelines, Clinical Accreditation Rehabilitation Facilities (CARF), Behavioral Health, and the Office of Inspector General (OIG). Assists with planning, developing, directing and evaluating health information and other functions. Demonstrates skill in budgeting, contracting, procurement and property management. In the absence of the CHIM, incumbent functions as Acting Chief of HIM, and is responsible for the overall management of the Section's program and function. Work Schedule: Monday-Friday; 08:00am-4:30pm Telework: Not Available Virtual: This is not a virtual position. Functional Statement #: 00000 Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized

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: 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. HIM Certification through AHIMA. English Language Proficiency. MRAs must be proficient in spoken and written English. See 38 U.S.C. § 7403(f). 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: Medical Records Administrator (Assistant Chief (ACHIM)), GS-12 Experience. One year of creditable experience equivalent to the next lower grade level that demonstrates all the KSAs described at that level. Certification: Employees at this level must have a HIM Certification. Knowledge, Skills, and Abilities (KSAs). In addition to the experience above, the candidate must demonstrate the following KSAs: Skill in managing various projects and processes, which includes the ability to develop new or improved solutions to complex technical problems in health information management. Ability to advise management and staff on a wide range of] health information management p