Medical Records Administration Specialist

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.

01Basic Requirements

1. United States 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). 2. 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. 3.

02Certification

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: Mastery certification obtained through the American Health 2 Information Management Association (AHIMA) or the American Association of Professional Coders (AAPC). To be acceptable for qualification, the specific certification must represent a comprehensive competency in the occupation.

Stand-alone specialty certifications do not meet the definition of mastery level coding certification and are not acceptable for qualifications. OR, Health Information Management (HIM) Certification through AHIMA: To be acceptable for qualifications, the specific certification must represent a comprehensive competency in the occupation. OR, Health Data Analyst Certification through AHIMA: This is limited to certification obtained through AHIMA.

To be acceptable for qualifications, the specific certification must certify mastery in health data analysis. 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).

03Grade 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 above Medical Records Administration Specialist, GS-7: Experience: In addition to the basic requirements, one year of creditable experience equivalent to the next lower grade level that demonstrates the knowledge, skills, abilities, and other characteristics described at that level.

OR, Education: (Advanced Entry-Level Placement). Applicants who meet the GS-5 grade level may be appointed at the GS-7 grade level, if they possess a bachelor's degree from an accredited college or university in a major field of study in health information management, with an exemplary academic record as demonstrated by: i.

A 3.0 or higher-grade point average (GPA) out of a possible 4.0 GPA ("B" or better), as recorded on their official transcript or as computed based on four years of education, or as computed based on courses completed during the final two years of the curriculum; OR ii.

A 3.5 GPA or higher out of a possible 4.0 GPA ("B+" or better) based on the average of the required courses completed in the major field of study, or the required courses completed in the major field of study during the final two years of the curriculum. Demonstrated Knowledge, Skills, and Abilities (KSA's).

In addition to the requirements above, candidates must demonstrate all of the following KSAs: Knowledge of current classification systems, such as International Classification of Diseases, Current Procedural Terminology, and the Healthcare Common Procedure Coding System (HCPCS). Ability to effectively communicate written and verbal with medical center staff, patients, and external entities.

Ability to use data collection and analytical techniques for purposes of review, quality control, studies, and analysis of health information. Ability to utilize computer applications with varied functions to produce a wide range of reports, to abstract records, collect and analyze data and present results in various formats. Ability to work independently, adapt to shifting priorities, and meet deadlines.

Medical Records Administration Specialist, GS-9: Experience: In addition to the basic requirements, one year of creditable experience equivalent to the next lower grade level that demonstrates the knowledge, skills, abilities, and other characteristics described at that level.

OR, Education: Education equivalent to two full years of progressively higher level graduate education or a master's degree or equivalent graduate degree from an accredited college or university in a field directly related to health information management. Demonstrated Knowledge, Skills, and Abilities. In addition to the requirements above, candidates must demonstrate all of the following KSAs: Knowledge of medical and legal requirements related to health information management and health records.

Ability to provide technical advice and guidance on health information management practices. Skill in extracting data from various sources and analyzing health information to create reports. Skill in researching, interpreting, and applying health information management guidelines. Knowledge of performance and process improvement techniques to develop new or improved solutions in health information management.

Medical Records Administration Specialist, GS-11: Experience: In addition to the basic requirements, one year of creditable experience equivalent to the next lower grade level that demonstrates the knowledge, skills, abilities, and other characteristics described at that level. OR, Education: Education equivalent to three 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 management.

Demonstrated Knowledge, Skills, and Abilities. In addition to the requirements above, candidates must demonstrate all of the following KSAs: Skill in performance and process improvement techniques to develop and implement new or improved solutions in health information management. Ability to advise management and staff, at various levels, regarding health record documentation requirements and health information management practices based on current industry standards, policies, statues, laws, and regulations.

Ability to plan, justify, develop, evaluate, assess, monitor, and advise on current health information management processes and recommend changes in policies or procedures. Ability to determine and evaluate compliance with legal, ethical, and regulatory guidelines and accrediting bodies, as they apply to health information management. Ability to acquire, manage, analyze, interpret, and transform data into accurate, consistent, and meaningful information. Continued in Education section

Duties of the Medical Records Administration Specialist include, but are not limited tol: 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 (TJC) standards, VHA regulations and medico-legal requirements; current federal codes pertinent to health records; VHA policy memoranda, directives, handbooks and program guides pertinent to health information management; medical coding (ICD, CPT, HCPCS) and reimbursement methodologies; medical and procedural terminology; anatomy and physiology; regulations governing confidentiality of health records; release of information laws and statutes; and all policies/procedures pertaining to VHA health records Keeps current on emerging issues and trends in the HIM field, including process improvement initiatives, the electronic health record (EHR), coding and computer­assisted coding, the revenue cycle, release of information and privacy issues, records management, medical speech recognition, transcription and data entry, and health information exchange Keeps HIM and clinical staff abreast of changing technology in electronic systems used to collect, process, code, protect and store health information.

Participates in various VAMC, VISN and national committees requiring HIM subject matter expertise Performs audits and analyses, preparing and presenting findings and recommendations to the CHIM, Service Line Leaders and medical staff. Assures the accuracy and timeliness of the capturing of patient services charges (workload) in accordance with all applicable laws and regulations. Reviews, analyzes and reports HIM performance monitors.

Advises Principal Investigators and other clinical staff on methodologies related to retrieval of health care data for specific studies. Performs data retrieval for special studies as needed Utilizes advanced knowledge of VHA data sources, such as VHA Support Service Center (VSSC) and the Corporate Data Warehouse (CDW), to complete analyses of VA Medical Center data. Analyzes and evaluates on a quantitative basis, the effectiveness of the HIM program and operations in meeting established goals and objectives.

Analyzes program performance data to identify areas needing improvement May review and test HIM related software patches; test and troubleshooting EHR menu options and functional issues when HIM users report application errors; perform equipment needs analysis for new or replacement equipment and/or equipment repair; submit work orders or Remedy tickets for correction to HIM software errors.

Is the facility expert for software and computer applications related to HIM to provide technical assistance to HIM staff (e.g., coding, ROI, dictation, and medical speech recognition software) Serves as point of contact for health record corrections to ensure documentation accurately reflects care delivered and reported. Documentation corrections may consist of retracting erroneous notes, re-titling notes, assigning notes to or removing from consult requests.

Collaborates on improperly identified documents with clinicians, Clinical Applications Coordinators (CACs) and others who report problems.

Reassigns, rescinds, and removes documents when they have been entered or uploaded incorrectly Provides education when dealing directly with physicians, nurses and other clinical providers requesting completion or adjustment of 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 VISN or VHA 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 new templates or additions/correction to existing templates (e.g., clinical reminder dialogs, documentation templates, PowerForms ) Reviews requests for new paper forms and assists in the creation and implementation of electronic versions of these forms so that they are always available to EHR users Work Schedule: Monday-Friday, 8:00am-4:30pm, subject to change based on the needs of the service.

Telework: Available Virtual: This is not a virtual position. Functional Statement #: GS-5, 564-01686-F; GS-7, 564-01687-F; GS-9, 564-01688-F; GS-11, 564-01689-F Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized