Medical Records Administrator (Chief (CHIM))

01Basic 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: 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. NOTE. See paragraph 2a above for a detailed definition of Coding Certification. OR; HIM Certification through AHIMA. NOTE. See paragraph 2d above for a detailed definition of HIM Certification. OR; Health Data Analyst Certification through AHIMA. NOTE. See paragraph 2c above for a detailed definition of Health Data Analyst 4 Certification. NOTE.

HIMs Certification is required for all positions above the full performance level. Loss of Credential. Following initial certification, credentials must be maintained through rigorous continuing education, ensuring the highest level of competency for employers and patients. An employee in this occupation who fails to maintain the required certification must be removed from the occupation which may result in termination of employment.

At the discretion of the appointing official, an employee may be reassigned to another occupation for which he/she qualifies, if a placement opportunity exists. Grandfathering Provision. All persons employed in VHA as an MRA are considered to have met all qualification requirements for the title, series, and grade held, including positive education, and [registration and/or] certification that are part of the basic requirements of the occupation.

For employees who do not meet all the basic requirements in this standard, but who met the qualifications applicable to the position at the time they were appointed, the following provisions apply: (1) Such employees may be reassigned, promoted up to, and including, the full performance (journeyman) level, or [changed to lower grade] within the occupation, but may not be promoted beyond the (journeyman) level or placed in supervisory or managerial positions. English Language Proficiency.

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

02Grade Determinations

Medical Records Administrator (Chief (CHIM)), GS-12: 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. NOTE. See paragraph 2d of this appendix for detailed definitions of HIM Certification.

AND; Demonstrated 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. 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.

Customer service skills necessary to effectively communicate (written and verbal) and interact with all levels of hospital personnel, physicians, patients, and outside agencies. Ability to deal effectively with sensitive and/or complex situations. Reference: For more information on this qualification standard, please visit https://www.va.gov/ohrm/QualificationStandards/.

03Physical Requirements

See VA Directive and Handbook 5019.

Major duties include but are not limited to: 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 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. Must provide detailed technical expertise in health records science and other very technical aspects of HIM.

Maintains all health information input into the local VistA database and assures timely transmission of that data into all VA centralized databases - most frequently those maintained at the Austin Data Processing Center. Must assure that all health information that is coded and abstracted meets the requirements of the VA and/or TJC and is consistent with professional health records standards.

Recommends improvements in health record documentation used to provide patient care, to optimize VERA workload, third party reimbursement and to manage resources. 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. Responsible for assuring that all patients have a complete, accurate, and timely record of their health care at the facility.

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.

Has the full complement of HIM supervisory responsibility including coding, record completion, file room, scanning, release of information, and transcription and which consists of a mixture of HT38 (675 and 669) and T5 positions. Develops work improvement plans, recommending personnel actions as necessary. Responsible for maintenance and evaluation of health records and assuring legal requirements for care are met.

Plays a central role in developing and coordinating internal review systems to assure that both clinical and administrative activities comply with agency and accrediting and regulatory requirements. Work Schedule: Full-time, Monday - Friday, 8:00am - 4:30pm Telework: Eligible for ad-hoc per supervisor Virtual: This is not a virtual position. Functional Statement #: 13491F