Medical Records Administrator
Duties include, but are not limited to:
Assists the Chief, Health Information Management (CHIM) and the HIM Department in identifying and setting short and long range goals, program objectives and tasks to meet the mission and vision of the VAMC. Provides subject matter expertise to Service Line Leaders, and medical center staff. Interprets and applies The Joint Commission standards, VA regulations and medico-legal requirements. Provides training for HIM, clinical and administrative staff on HIM topics. Designs and performs quality improvement projects regarding HIM issues. Assists the CHIM in preparing various presentations. Keeps current on emerging issues and trends in the health information management field, including process improvement initiatives for HIM, the electronic health record, coding and computer assisted coding, the revenue cycle, release of information and privacy issues, records management, transcription and data entry, and data exchange. Performs audits and analyses, preparing and presenting findings and recommendations to the CHIM, Service Line Leaders and medical staff. Advises Principal Investigators and other clinical staff relating to methodologies of retrieving health care data for specific studies. Participates in various VAMC, VISN and national committees requiring health information management subject matter expertise. Is the facility expert for COTS software related to HIM to provide technical assistance to HIM staff (e.g., coding, ROI and dictation software). Serves as the point of contact for medical record corrections. Reassigns, rescinds and removes documents when they have been entered or uploaded incorrectly. Establishes criteria and provides education when dealing directly with physicians, nurses and other providers requesting them to complete or adjust pertinent parts of the health records, which are found to be inconsistent or incomplete upon analysis. Assists and provides guidance to supporting clinical services to capture required medical information on patients for computer database input. Selects, compiles and trends medical, surgical and statistical data from numerous components of the health record. Retrieves diagnostic and statistical data for various reports required locally or by Central Office. May assign User Classes to users at the request of the Chief HIM; responds to questions or issues related to that user class. Reviews requests for paper forms, creating electronic versions of these forms so that they are always available to users by computer. Serves as the Contracting Officer Representative for HIM contracts such as Coding, Transcription, Scanning, Records Management, if applicable. Work Schedule:
7:
30 am - 4:
00 pm, Monday - Friday Financial Disclosure Report:
Not required Retention/Recruitment Incentives:
Not authorized PCS Expenses:
Not authorized 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. Three years of experience in the field of medical records that included the preparation, maintenance, and management of medical records and health information systems. At least 1 year of this experience must be comparable to a GS-4 level position. NOTE:
Successfully completed training for health information technicians in a school accredited by the American Health Information Management Association (AHIMA) at the time the program was completed may be substituted for 1 year of experience. No credit may be given for partial completion of such training. OR, Education. Education equivalent to a baccalaureate degree from an accredited university or college. OR, Experience/Education Combination. Equivalent combinations of experience and education may be used to meet basic requirements. Creditable Experience (a) Knowledge of Current Medical Record Administration Practices. To be creditable, experience must have required the use of knowledge, skills, abilities, and other characteristics (also referred to as core competencies) associated with current health information practice. This knowledge may be evidenced by one or more of the following:
1. The equivalent of 1 year of active practice in the health information management field that included knowledge of the content and uses of health records, computerized information systems, and disease and procedural indices; ability to apply the concepts, principles and practices of health information administration; ability to apply knowledge of anatomy, pathophysiology, and medical terminology to health information management functions. OR, 2. Maintenance/possession of an active credential from AHIMA as a Registered Health Information Administrator (RHIA) or Registered Health Information Technician (RHIT); OR, 3. Successful completion of academic course work leading to an advanced degree in health information management or a related field. Quality of Experience. Experience is only creditable if it is in health information management and is directly related to the position to be filled or in a related field, such as quality assurance, Health Insurance Portability & Accountability Act (HIPAA) privacy, or electronic medical record implementation. Qualifying experience must also be at a level and complexity comparable to medical record management experience at the next lower grade level. Registration is offered by AHIMA as a Registered Health Information Administrator (RHIA) or Registered Health Information Technician (RHIT) and is highly desirable. Grade Determinations. In addition to the basic requirements for employment, the following criteria must be met when determining the grade of candidates. GS-11 (a) Experience. At least 1 year of experience comparable to the next lower grade level that demonstrates the KSAs described at that level. In addition, the candidate must demonstrate the following KSAs:
OR, (b) Education. Education equivalent to 3 full years of progressively higher level graduate education or a Ph.D. or equivalent doctoral degree from an accredited university or college in the field of health information. (c)Demonstrated Knowledges, Skills, and Abilities 1. Skill in project management and process improvement, which includes the ability to develop new or improved solutions to complex technical problems in health information management; 2. Ability to advise management and staff about adequate medical record documentation, health information services, and/or computerized patient records based on current statutes and standards; 3. Ability to plan for, justify, test, assess, and/or advise about the use of current and future software programs or information systems, implement and integrate such products into current health information management processes, and recommend changes in policies or procedures; 4. Ability to interpret, implement, and apply knowledge of privacy and confidentiality requirements affecting individual patient/protected health information;5. Demonstrated comprehensive knowledge of medical and legal requirements related to both paper and electronic medical records; 6. Ability to communicate and negotiate with professionals in higher level positions; 7. If the position is supervisory in nature, ability to plan, develop, direct, and evaluate health information or related functions; 8. If the position is supervisory in nature, ability to successfully apply principles and techniques of sound human resources management; and9. If the position is supervisory in nature, skill in administrative management, i.e., budgeting, contracting, procurement, and property management. (d) Assignments. This is considered the full performance level for non-supervisory positions. Individuals at the GS-11 level may be assigned supervisory and program management responsibilities at smaller medical centers where the clinical program does not include a wide range of acute care activities and where the medical records unit staff is predominately Medical Record Technicians. Employees may also be assigned supervisory and program responsibilities for a portion of the medical records program at medium to complex medical centers that provide a wide range of acute care activities but where a higher graded Medical Record Administrator has overall program responsibilities. Preferred
Experience:
Knowledge and experience forming policies and procedures related to HIM. Experience with Medical Records Committee preparation and presentations, and the ability to train physician providers. References:
VA HANDBOOK 5005/15, PART II, APPENDIX G33. The full performance level of this vacancy is GS-11. Physical Requirements:
Mostly sedentary in nature. Must be able to lift 30-40 lbs. of records in boxes.
Estimated Salary: $20 to $28 per hour based on qualifications.
Assists the Chief, Health Information Management (CHIM) and the HIM Department in identifying and setting short and long range goals, program objectives and tasks to meet the mission and vision of the VAMC. Provides subject matter expertise to Service Line Leaders, and medical center staff. Interprets and applies The Joint Commission standards, VA regulations and medico-legal requirements. Provides training for HIM, clinical and administrative staff on HIM topics. Designs and performs quality improvement projects regarding HIM issues. Assists the CHIM in preparing various presentations. Keeps current on emerging issues and trends in the health information management field, including process improvement initiatives for HIM, the electronic health record, coding and computer assisted coding, the revenue cycle, release of information and privacy issues, records management, transcription and data entry, and data exchange. Performs audits and analyses, preparing and presenting findings and recommendations to the CHIM, Service Line Leaders and medical staff. Advises Principal Investigators and other clinical staff relating to methodologies of retrieving health care data for specific studies. Participates in various VAMC, VISN and national committees requiring health information management subject matter expertise. Is the facility expert for COTS software related to HIM to provide technical assistance to HIM staff (e.g., coding, ROI and dictation software). Serves as the point of contact for medical record corrections. Reassigns, rescinds and removes documents when they have been entered or uploaded incorrectly. Establishes criteria and provides education when dealing directly with physicians, nurses and other providers requesting them to complete or adjust pertinent parts of the health records, which are found to be inconsistent or incomplete upon analysis. Assists and provides guidance to supporting clinical services to capture required medical information on patients for computer database input. Selects, compiles and trends medical, surgical and statistical data from numerous components of the health record. Retrieves diagnostic and statistical data for various reports required locally or by Central Office. May assign User Classes to users at the request of the Chief HIM; responds to questions or issues related to that user class. Reviews requests for paper forms, creating electronic versions of these forms so that they are always available to users by computer. Serves as the Contracting Officer Representative for HIM contracts such as Coding, Transcription, Scanning, Records Management, if applicable. Work Schedule:
7:
30 am - 4:
00 pm, Monday - Friday Financial Disclosure Report:
Not required Retention/Recruitment Incentives:
Not authorized PCS Expenses:
Not authorized 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. Three years of experience in the field of medical records that included the preparation, maintenance, and management of medical records and health information systems. At least 1 year of this experience must be comparable to a GS-4 level position. NOTE:
Successfully completed training for health information technicians in a school accredited by the American Health Information Management Association (AHIMA) at the time the program was completed may be substituted for 1 year of experience. No credit may be given for partial completion of such training. OR, Education. Education equivalent to a baccalaureate degree from an accredited university or college. OR, Experience/Education Combination. Equivalent combinations of experience and education may be used to meet basic requirements. Creditable Experience (a) Knowledge of Current Medical Record Administration Practices. To be creditable, experience must have required the use of knowledge, skills, abilities, and other characteristics (also referred to as core competencies) associated with current health information practice. This knowledge may be evidenced by one or more of the following:
1. The equivalent of 1 year of active practice in the health information management field that included knowledge of the content and uses of health records, computerized information systems, and disease and procedural indices; ability to apply the concepts, principles and practices of health information administration; ability to apply knowledge of anatomy, pathophysiology, and medical terminology to health information management functions. OR, 2. Maintenance/possession of an active credential from AHIMA as a Registered Health Information Administrator (RHIA) or Registered Health Information Technician (RHIT); OR, 3. Successful completion of academic course work leading to an advanced degree in health information management or a related field. Quality of Experience. Experience is only creditable if it is in health information management and is directly related to the position to be filled or in a related field, such as quality assurance, Health Insurance Portability & Accountability Act (HIPAA) privacy, or electronic medical record implementation. Qualifying experience must also be at a level and complexity comparable to medical record management experience at the next lower grade level. Registration is offered by AHIMA as a Registered Health Information Administrator (RHIA) or Registered Health Information Technician (RHIT) and is highly desirable. Grade Determinations. In addition to the basic requirements for employment, the following criteria must be met when determining the grade of candidates. GS-11 (a) Experience. At least 1 year of experience comparable to the next lower grade level that demonstrates the KSAs described at that level. In addition, the candidate must demonstrate the following KSAs:
OR, (b) Education. Education equivalent to 3 full years of progressively higher level graduate education or a Ph.D. or equivalent doctoral degree from an accredited university or college in the field of health information. (c)Demonstrated Knowledges, Skills, and Abilities 1. Skill in project management and process improvement, which includes the ability to develop new or improved solutions to complex technical problems in health information management; 2. Ability to advise management and staff about adequate medical record documentation, health information services, and/or computerized patient records based on current statutes and standards; 3. Ability to plan for, justify, test, assess, and/or advise about the use of current and future software programs or information systems, implement and integrate such products into current health information management processes, and recommend changes in policies or procedures; 4. Ability to interpret, implement, and apply knowledge of privacy and confidentiality requirements affecting individual patient/protected health information;5. Demonstrated comprehensive knowledge of medical and legal requirements related to both paper and electronic medical records; 6. Ability to communicate and negotiate with professionals in higher level positions; 7. If the position is supervisory in nature, ability to plan, develop, direct, and evaluate health information or related functions; 8. If the position is supervisory in nature, ability to successfully apply principles and techniques of sound human resources management; and9. If the position is supervisory in nature, skill in administrative management, i.e., budgeting, contracting, procurement, and property management. (d) Assignments. This is considered the full performance level for non-supervisory positions. Individuals at the GS-11 level may be assigned supervisory and program management responsibilities at smaller medical centers where the clinical program does not include a wide range of acute care activities and where the medical records unit staff is predominately Medical Record Technicians. Employees may also be assigned supervisory and program responsibilities for a portion of the medical records program at medium to complex medical centers that provide a wide range of acute care activities but where a higher graded Medical Record Administrator has overall program responsibilities. Preferred
Experience:
Knowledge and experience forming policies and procedures related to HIM. Experience with Medical Records Committee preparation and presentations, and the ability to train physician providers. References:
VA HANDBOOK 5005/15, PART II, APPENDIX G33. The full performance level of this vacancy is GS-11. Physical Requirements:
Mostly sedentary in nature. Must be able to lift 30-40 lbs. of records in boxes.
- Department:
0669 Medical Records Administration - Salary Range:
$73,096 to $95,023 per year
Estimated Salary: $20 to $28 per hour based on qualifications.
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