Medical Records Admintrator Specialist

Job Title

Duties include but are not limited to the following:

• Assists the Chief, Health Information Management 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 standards, VA regulations and medico-legal requirements; current Federal Codes pertinent to medical records; Veterans Administration policy memoranda, directives and handbooks pertinent to health information management; ICD-CM coding principles and nomenclature and the MS-DRG system; CPT and E&M rules; medical and procedural terminology; anatomy and physiology, regulations governing confidentiality of medical records; release of information laws and statutes; and any policies pertaining to VA medical 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 various presentations.
• Keeps current on emerging issues and trends in the health information management field, including process improvement initiatives for HIM, the electronic health record, coding and computer assisted coding, the revenue cycle, release of information and privacy issues, records management, transcription and data entry, and data exchange.
• Keeps HIM and clinical staff abreast of changing technology in electronic systems used to collect, process, code, protect and store health information.
• Performs audits and analyses, preparing and presenting findings and recommendations to the CHIM, Service Line Leaders and medical staff. Reviews, analyzes and reports HIM performance monitors.
• Advises Principal Investigators and other clinical staff relating to methodologies of retrieving health care data for specific studies. Performs data retrieval for special studies as needed
• Participates in various VAMC, VISN and national committees requiring health information management subject matter expertise.
• May review and test HIM related VistA software patches; test and trouble-shooting VistA menu options and functional issues for users; perform equipment needs analysis for new or replacement equipment and/or equipment repair; submit work orders for correction to software errors.
• Supports contracting services related to HIMS needs and provide technical assistance to HIM staff (e.g., coding, ROI and dictation software).
• Provide support for health information documentation corrections, consist of retracting erroneous notes, re-titling notes, reassigning notes to or removing from consult requests or appointments and problem solves other documentation and workload issues; collaborate with with clinicians, Clinical Applications Coordinators (CACs) and others who report problems.
• Establishes criteria and provides education when dealing directly with physicians, nurses and other providers requesting them to complete or adjust 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 Central Office.
• Supports information governance principals, identifies variances in data, performs analysis of data, identifying discrepancies and dubious practices, collaborates with all levels of leadership and staff to problem-solve and resolve with appropriate solutions, striving for greater efficiencies, accessibility, improve quality and integrity of data for making better decisions.

Work Schedule: Monday-Friday 7:00am to 3:30pm

Telework: Ad Hoc Emergency Telework MAY BE Authorized

Virtual: This is not a virtual position.

Functional Statement #: 000000

Relocation/Recruitment Incentives: Not Authorized

Permanent Change of Station (PCS): Not Authorized