Medical Records Administration Specialist

Job Title

Health Information Management Specialist

Duties

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.

Provides training for HIM, clinical and administrative staff on HIM topics. Designs and performs quality improvement projects regarding HIM issues. Assists the CHIM in preparing and conducting various presentations.

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.

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.

Work Schedule

Monday - Friday, 7:30am - 4:00pm

Telework

Available on an ad-hoc basis.

Functional Statement #

61528-0 / 61529-0 / 61530-0 / 61531-0

Relocation/Recruitment Incentives

Not authorized.

Permanent Change of Station (PCS)

Not authorized.