Summary This position is located in the Health Information Management Section of Health Administrative Service at the Salisbury VA Medical Center. Medical Records Administrators (MRAs) in VHA perform or supervise work concerned with the management of a health record program or the provision of services related to medical record administration/health information services. MRAs manage, preserve, analyze, and supervise the use of diagnostic and therapeutic health records/health information management. Responsibilities The Medical Records Administrator - Chief CHIM duties includes, but are not limited to the following: Serves as Chief of Health Information Management (CHIM) with full program responsibility for all facets of the Health Information Management (HIM) program and processes. Must ensure HIM program meets and/or exceed national HIM policies, procedures, and performance metrics. Responsible for the administrative management of health records, which includes planning, managing, advising, and directing 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. Creates and monitors systems to ensure accurate, timely, and complete health records, in accordance with VHA policy and TJC health information protocols. Measures ongoing intradepartmental performance by establishing priorities, collecting data, monitoring and reporting outcomes, using valid and reliable techniques to analyze trends and variation, and taking appropriate action based on findings. 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. Develops policies, processes, and procedures that address all VA, Federal, regulatory, and accrediting requirements for HIM. Evaluates health records program and independently determines the nature and extent of problem areas. Develops recommendations and solutions for program improvement. Develops and implements innovative solutions to correct technical, complex problems. Clinical support role: The incumbent is a key advisor to the Chief of Staff, Executive Management, and clinicians and is responsible for providing technical guidance on health information issues such as documentation requirements, liability issues, advance directives, informed consent, release of information, transcription/speech recognition, health information exchange, etc. Recommends improvements in health record documentation used to provide patient care, to optimize VERA workload, third party reimbursement and to manage resources. Completes internal quality assurance reviews to ensure employee performance and that work meets quality and quantity standards. Establishes monitors to ensure the timeliness of health record entries and reports findings with subsequent trending of data. Provides management officials with health record review results and trends on an ongoing basis. Monitors and reports delinquent records by number, @type of deficiencies and responsible provider. Serves to guide and assist on research projects and is a resource for patient data on both patient-specific and aggregate databases. Represents HAS and acts as subject matter expert at the facility-wide Health Records Committee. In this capacity, the incumbent advises the committee on health record issues; including VA requirements, TJC standards, record retrieval processes, health record components, systems, goals, electronic records, etc. Responsible for assuring that all patients have a complete, accurate, and timely record of their health care at the facility. Must assure that such information is appropriately stored and readily available for the provision of medical services to the patients. As a resource for the medical center, incumbent conducts training programs in various areas 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. Performs the administrative and personnel management functions relative to staff supervised. Establishes guidelines and performance expectations for staff, which are clearly communicated through the formal employee performance management system. Observes workers' performance; demonstrates and conducts work performance critiques. Provides informal feedback and periodically evaluates employee performance. Resolves informal complaints and grievances. Work Schedule: Monday - Friday 8am - 4:30pm Telework: Not Available Virtual: This is not a virtual position. Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized Requirements Conditions of Employment You must be a U.S. Citizen to apply for this job. Selective Service Registration is required for males born after 12/31/1959. Must be proficient in written and spoken English. You may be required to serve a trial period. Subject to background/security investigation. Selected applicants will be required to complete an online onboarding process. Acceptable form(s) of identification will be required to complete pre-employment requirements (https://www.uscis.gov/i-9-central/form-i-9-acceptable-documents). Effective May 7, 2025, driver's licenses or state-issued dentification cards that are not REAL ID compliant cannot be utilized as an acceptable form of identification for employment. Participation in the seasonal influenza vaccination program is a requirement for all Department of Veterans Affairs Health Care Personnel (HCP). Qualifications 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. English Language Proficiency: MRAs must be proficient in spoken and written English. See 38 U.S.C. § 7403(f). 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. OR, HIM Certification through AHIMA. OR, Health Data Analyst Certification through AHIMA. NOTE: HIMs Certification is required for all positions above the full performance level. -- 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). 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 (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. Demonstrated Knowledge, Skills, and Abilities: i. Ability to determine and evaluate compliance with legal, ethical [and regulatory guidelines and accrediting bodies,] as they apply to health information management. ii. Ability to provide sound, technical guidance to staff [at various levels] about major program, legal, or procedural changes related to health information management. iii. 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. iv. Skill in analyzing [complex] data[, interpreting and trending results for effective management of the HIM program.] v. [Skill] in management/administration, which includes program planning, coordination, interpretation, supervision, consultation, negotiation, problem solving, and monitoring of HIM processes. vi. Ability to delegate authority, evaluate and oversee people and programs, accomplish program goals, and adapt to changing priorities. Preferred Experience: RHIT / RHIA credentials. Supervisor experience. 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: See VA Directive and Handbook 5019 Education Note: Only education or degrees recognized by the U.S. Department of Education from accredited colleges, universities, schools, or institutions may be used to qualify for Federal employment. You can verify your education here: http://ope.ed.gov/accreditation/. If you are using foreign education to meet qualification requirements, you must send a Certificate of Foreign Equivalency with your transcript in order to receive credit for that education. For further information, visit: https://sites.ed.gov/international/recognition-of-foreign-qualifications/. Additional Information Receiving Service Credit or Earning Annual (Vacation) Leave: Federal Employees earn annual leave at a rate (4, 6 or 8 hours per pay period) which is based on the number of years they have served as a Federal employee. Selected applicants may qualify for credit toward annual leave accrual, based on prior work experience or military service experience. This credited service can be used in determining the rate at which they earn annual leave. Such credit must be requested and approved prior to the appointment date and is not guaranteed. During the application process you may have an option to opt-in to make your resume available to hiring managers in the agency who have similar positions. Opting in does not impact your application for this announcement, nor does it guarantee further consideration for additional positions. This job opportunity announcement may be used to fill additional vacancies. This position is in the Excepted Service and does not confer competitive status. VA encourages persons with disabilities to apply. The health-related positions in VA are covered by Title 38, and are not covered by the Schedule A excepted appointment authority. If you are unable to apply online or need an alternate method to submit documents, please reach out to the Agency Contact listed in this Job Opportunity Announcement. Under the Fair Chance to Compete Act, the Department of Veterans Affairs prohibits requesting an applicant's criminal history prior to accepting a tentative job offer. For more information about the Act and the complaint process, visit Human Resources and Administration/Operations, Security, and Preparedness (HRA/OSP) at The Fair Chance Act.
