Performs or supervises work concerned with the management of a medical record program or the provision of services related to medical record administration/health information services and the Coding and Coding Compliance program. Manage, preserve, analyze and supervise the use of diagnostic and therapeutic medical records/health information management and develop policies and procedures and provide advice on the use of medical records and health information management.Serves as the Assistant Chief of Health Information Management (HIM) charged with full responsibility, both technically and administrative, for the daily operation of the HIM department consisting of medical record activities - coding, analyzing, transcription, release of information, file room and scanning programs. Direct supervisor to the Coding and Coding Compliance Department which is a stand-along section. Collects and processes data for various reports, surveys, and research projects. Assists physicians and other health professionals in obtaining health record information to be used in research projects. Provides technical guidance to the unit supervisors and lead clerks while providing support to each unit in the absence of the section supervisor. Keeps abreast of changes that are constantly being made in the health information field as well as allied medical fields. Prepares training materials and participates in orientation and instructional activities as required. Assists with the development, evaluation, and updating of office procedures, manuals, policies and directives and in the effective administration and planning of the health information management program throughout all areas of the facility in order to give maximum support to the staff in the treatment of patients and research programs. Provides effective audits and monitors for all areas of responsibility. Develops performance standards and conducts performance evaluations. Participates in various facility, VISN and national committees requiring health information management subject matter expertise. Ensures that health record review activities are consistent with requirements established by VA Handbooks and directives are in compliance with Joint Commission standards and Scoring Guidelines, Clinical Accreditation Rehabilitation Facilities, Behavioral Health and The Inspector General. Instrumental in the success of HIM which includes the CDI, Coding and Coding Compliance programs. Develops policies and procedures to comply with new and/or changed programs such as Compliance, reasonable charges and others. Determines staffing, patters for the section and reassigning personnel to meet changing conditions. Advises medical staff, management, and others regarding Joint Commission, VISN, VA and medical/legal requirements for coding the health records.
Work Schedule: Full-time
I. BASIC REQUIREMENTS:
a. Citizenship. Citizen of the United States.
b. Education or Experience
(a) 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.
An associate's degree in the health information field plus 1 year of experience that included the preparation, maintenance, and management of medical records and health information systems.
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.
(2) Education. Education equivalent to a baccalaureate degree from an accredited university or college.
3) Experience/Education Combination. Equivalent combinations of experience and education may be used to meet basic requirements.
c. Grandfathering Provision. The following is the standard grandfathering policy for all Title 38 hybrid qualification standards. All persons employed in VHA in this occupation on the effective date of this qualification standard are considered to have met all qualification requirements for the title, series and grade held, including positive education and licensure/certification/registration that are part of the basic requirements of the occupation.
d. Physical Requirements - See information in Vacancy Announcement GRADE REQUIREMENTS.
2. GRADE REQUIREMENTS.
(1) 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.
2. Maintenance/possession of an active credential from AHIMA as a Registered Health Information Administrator (RHIA) or Registered Health Information Technician (RHIT);
3.Successful completion of academic course work leading to an advanced degree in health information management or a related field.
(2) 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.
(3) Part-Time Experience. Part-time experience as a medical record administrator is creditable according to its relationship to full-time workweek. For example, an MRA would receive 1 week of full-time credit for each 2 weeks of half-time work.
3. Grade Determinations. In addition to the basic requirements for employment, the following criteria must be met when determining the grade of candidates for the GS-12 level:
(a) Experience. At least 1 year of specialized experience comparable to the GS-11 level as stated above (Quality of Experience) demonstrating the following professional KSAs and demonstrate the potential to acquire the assignment specific KSAs indicated by an asterisk (*):
(b) Demonstrated Knowledge, Skills, and Abilities:
1.Ability to identify, define, and resolve managerial, administrative, and computerized medical record problems associated with unique, underdeveloped, and controversial aspects of medical record management;
*2. Skill in developing new policies and procedures for administering electronic medical record programs in order to improve program effectiveness and/or apply newly developed programs or theories to problems that require new approaches;
3. Ability to understand computerized patient record data systems that are meaningful to the medical center as a whole;
*4. Ability to teach new and continuing users in electronic health record and health data systems as appropriate to the current assignment;
*5. If supervisory, ability to manage assigned resources;
*6. If the position is supervisory in nature, the ability to provide the full range of supervisory duties which would include assignment of work; completing performance evaluations; selection of staff; and recommendation of awards, advancements, and, when appropriate, disciplinary actions.
Reference: VA Handbook 5005/15 Part II Appendix G323, Medical Records Administrator Qualification Standards
PHYSICAL DEMANDS: Work is sedentary. Sits comfortably to do the work. Some walking, standing, bending, carrying of light items such as papers, books, small parts. No special demands are required to perform the work.