Medical Records Administration Specialist

Medical Records Administration Specialist

Duties of the Medical Records Administration Specialist include, but are not limited to:

• 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 computer-assisted 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, per supervisor discretion

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