Medical Records Administrator (Chief (CHIM))

Job Title

Health Information Management Specialist

Duties

Duties include but are not limited to:

• Ensure HIM program meets and/or exceeds 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.
• Develop policies, processes, and procedures that address all VA, Federal, regulatory, and accrediting requirements for HIM.
• Develop recommendations and solutions for program improvement and implements innovative solutions to correct technical, complex problems.
• 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.
• Ensure 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.
• Key advisor to the Chief of Staff, Executive Management, and clinicians and is responsible for providing technical guidance on health information issues such as documentation requirements, liability issues, advance directives, informed consent, release of information, transcription/speech recognition, health information exchange, etc.
• Recommends improvements in health record documentation used to provide patient care, to optimize VERA workload, third party reimbursement and to manage resources.
• Represents MAS/HIM and acts as subject matter expert at the facility-wide Health Records Committee.
• Advises the committee on health record issues; including VA requirements, TJC standards, record retrieval processes, health record components, systems, goals, electronic records, etc.
• Key member of the Quality Improvement (QI) team, works closely with QI personnel, and is responsible for assuring that the facility is compliant with all TJC standards regarding health information.
• Responsible for assuring that all patients have a complete, accurate, and timely record of their health care at the facility.
• Support the information security program and manage much of the patient information database within VistA.
• Conducts training programs in various areas of 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 to include coordinating health information training for medical school students and residents to achieve conformance with prescribed standards.
• Provide consultation services to members of the Counsel's staff in areas dealing with health information.
• Actively participates at national and VISN levels as a resource person on health information matters and research activities related to health information and electronic health record (EHR) issues.
• Responsible for directing the operations of all personnel working within the HIM program and is regularly involved in labor relations and budget management.
• Collaborates with Human Resources to review and approve all HIM recruitment actions and vacancy announcements.
• Performs the administrative and personnel management functions relative to staff supervised.
• Establish guidelines and performance expectations for staff, which are clearly communicated through the formal employee performance management system.

Work Schedule: 8:00am - 4:30pm Monday - Friday, subject to change based on the needs of the facility.

Telework: Available

Virtual: This is not a virtual position.

Functional Statement #: 00212F

Relocation/Recruitment Incentives: Not Authorized.

Permanent Change of Station (PCS): Not Authorized.