Medical Records Administrator, HIMS Chief

Job Title

Chief Health Information Management Officer

Duties

Major duties include but are not limited to the following:

• Incumbent is directly responsible to the Chief and Assistant Chief, Health Administration Service who give general objectives.
• 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 standards, the Commission on Accreditation of Rehabilitation Facilities (CARF), and other regulatory and accrediting agencies.
• 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.
• Provides detailed technical expertise in health records science and other very technical aspects of health information. 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.
• Serves as the Chair of the Medical Record Committee (MRC), to include preparing agendas and overseeing the processes that is relative to Joint Commission standards. In addition, the CHIM also serves as Chair to the Clinical Documentation Improvement Committee.
• Serves as the key advisor to the Chief of Staff, Executive Management, Program Managers, to include Administrative Officers (AOs), clinicians and is responsible for providing technical guidance on health information issues such as documentation requirements, liability issues, advance directives, informed consent, patient privacy and confidentiality, et cetera.
• The incumbent is a key member of the Quality Improvement (QI) team, works closely with QI personnel, and is responsible for assuring the facility is in compliance with all The Joint Commission standards regarding health information.
• Responsible for assuring all patients have a complete, accurate, and timely record of their medical care at the facility, as well as assure such information is appropriately stored and readily available for the provision of medical services to the patients.
• Incumbent is responsible for leading the automation of all health information systems.
• As a resource for the institution, incumbent conducts training programs in health information management, medical terminology, health record documentation, and medico-legal matters. Incumbent is responsible for establishing formal affiliation with university programs in health information and precepting students from such programs. Incumbent is also responsible for coordinating health information training for medical school students and residents to achieve conformance with prescribed standards.
• Incumbent provides direct support to Regional Counsel.
• The CHIM at this level has the full complement of HIM supervisory responsibility including coding, file room, scanning, release of information, clinic setup, creating local and managing electronic encounter forms, monitoring and managing and monitoring medical record (note suppression) and transcription and which consists of a mixture of HT38 (675 and 669) and T5 positions.
• Responsible for maintenance and evaluation of health records, and assuring legal requirements for care are met. Performs these duties as the facility expert but does not involve substantial line responsibility for establishing and implementing overall clinical policies.
• Plays a central role in developing and coordinating internal review systems to assure both clinical and administrative activities are in compliance with agency and accrediting and regulatory requirements.
• Performs other related duties as assigned.

Work Schedule: Monday through Friday, 8:00 am to 4:30 pm (Pacific Standard Time)

Telework: Adhoc (but Chief must be onsite or within 50 miles from Loma Linda VAMC).

Virtual: This is not a virtual position.

Functional Statement #: 000000

Relocation/Recruitment Incentives: Not Authorized.

Permanent Change of Station (PCS): Not Authorized.