Medical Records Administrator (Assistant Chief Health Information Managementt)

Job Title

Assists the Chief HIM (CHIM) in establishing policies, responsibilities, and requirements for health information management (HIM) related matters, such as health record documentation, coding and clinical documentation improvement, records management, release of information, file room/scanning, transcription and medical speech recognition, as well as the overall management of health information and Veteran's health records.

Oversees implementation and adherence to HIM industry standards, policies, procedures, laws, regulations, and accrediting bodies.

Ensures the facility is in compliance with applicable standards by completing HIM audits, healthcare data reports, and statistical information, for timely and accurate reporting.

Establishes, implements, and monitors HIM performance through metrics, productivity measures, benchmarking, and other applicable tools.

Provides consultation and management support to the above units to ensure smooth operation of a customer-focused, forward-thinking and efficiently managed department.

Functions as Acting Chief of the Section and is responsible for overall management of the Sections' program and function.

Aids with the overall effective administration and planning of the HIM program throughout all areas of the facility in order to give maximum support to the staff in the treatment of patients.

Performs documentation corrections: documentation errors consist of retracting erroneous notes, re-titling notes, assigning notes to or removing from consult requests.

Analyzes workflow to determine potential problem areas and makes recommendations to correct these areas and improve coordination between the various units.

Obtains, organizes, files, and retrieves reports, correspondence, and financial data for use in preparing status reports, briefings, and presentations.

Identifies and recommends ways of eliminating, combining, simplifying, or improving procedures and processes.

Establishes criteria and provides education when dealing directly with physicians, nurses and other clinical providers requesting them to complete or adjust pertinent parts of the health records, which are found to be inconsistent or incomplete upon analysis.

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 Central Office.

Prepares training materials and participates in orientation and instructional activities as required.

Advises management and hospital staff members on policies, procedures and adequacy of record content, and on training and teaching of clerical personnel in health record functions.

Participates in various health record review activities.

Assists the CHIM in identifying and setting short- and long-range goals, program objectives and tasks to meet the mission and vision of the medical center.

Assists with planning, developing, directing and evaluating health information and other functions.

Demonstrates skill in budgeting, contracting, procurement and property management.

Designs and implements a program to measure compliance with documentation standards for all areas of the medical center including: inpatient, outpatient, home health, long term care, behavioral health, rehabilitation and fee basis.

Aids in a variety of projects and is responsible for screening, abstracting and tallying data from records and computer-generated reports.

Serve as a consultant to provide guidance and advise researchers on methods for gathering data.

Assists in selected miscellaneous retrospective medical record review/data abstraction projects to support medical center Quality Management data collection activities.

Advises staff in problem areas about quantitative and qualitative analysis of health records and determines acceptability of content.

Consults with physicians and other clinicians regarding health record deficiencies as appropriate.

Assists with the retrieval, review, analysis and reporting of HIM performance monitors and other medical record review topics.

Work Schedule: Monday - Friday 8:00a.m. - 4:30p.m. Work schedule subject to change based on agency needs.

Telework: Ad hoc

Virtual: This is not a virtual position.

Functional Statement #: 619-552788F

Relocation/Recruitment Incentives: Not Authorized

Permanent Change of Station (PCS): Not Authorized