Medical Records Administration Specialist

Veterans Health Administration•Oklahoma City, OK

17h•Onsite

About The Position

This position is in the Health Information Management (HIM) Section of the Medical Administration Service at the Oklahoma City VA Healthcare System. The Medical Records Administration Specialist manages, analyzes, and oversees health records and information; performs data mining, reporting, workflow analysis, quality improvement, and health record reviews; provides training; presents findings to leadership; and supports operational decisions. The specialist serves as a technical expert in HIM and advises staff on documentation, coding, liability, advance directives, informed consent, scanning, speech recognition, release of information, state reporting, record control, confidentiality, and regulatory requirements. The role researches and coordinates projects and studies, develops study plans and tools, analyzes data, prepares findings and recommendations, and produces management reports. It analyzes HIM workflows and review systems, identifies improvement opportunities, and recommends or implements changes to improve productivity, data quality, performance, and turnaround times. The role supports the development and maintenance of health information policies and procedures, ensuring compliance with VHA directives, federal regulations, Joint Commission standards, and medico-legal requirements. It conducts quantitative and qualitative record reviews and quality assurance studies, and compiles, abstracts, retrieves, analyzes, and interprets medical, legal, clinical, diagnostic, procedural, workload, and statistical data for operational, research, and special-study needs. The specialist helps ensure accurate and timely patient service charge and workload capture. This includes reviewing documentation, encounter and registration data, and charge records; resolving errors and missing or suspended charges; coordinating CPT/HCPCS coding and Charge Description Master updates; auditing reports; and working with clinical, administrative, informatics, revenue, and finance teams to improve encounter accuracy. The position serves as a liaison for the electronic health record and automated clinical applications. It analyzes information flows, tests software and patches, troubleshoots issues, submits work orders or Remedy tickets, and assists with HIM applications, templates, and forms. It also helps correct health records and works with clinical staff to resolve incomplete, inconsistent, or improperly identified documentation. The specialist provides training to HIM, clinical, and administrative staff on HIM practices, documentation, coding, EHR functions, privacy, release of information, revenue cycle processes, and emerging technologies. The role supports HIM leadership with goals, quality initiatives, audits, presentations, performance monitoring, and planning, and participates in facility, VISN, and national committees. The schedule is full-time, Monday through Friday, 8:00 AM to 4:30 PM. Telework is not available, and the position is not virtual. The full performance level is GS-11; selection may be at GS-5 through GS-11.

Requirements

U.S. citizenship, subject to the stated exception for non-citizens when qualified candidates cannot be recruited under applicable law.
Proficiency in written and spoken English.
Meet the basic experience or education requirement: three years of creditable medical records experience; or a bachelor's degree or higher in health information management or a related degree with at least 24 semester hours in HIM/HIT; or an equivalent combination of education and experience.
Hold an eligible certification: coding certification through AHIMA or AAPC, HIM certification through AHIMA, or Health Data Analyst certification through AHIMA; an applicable grandfathering provision may also qualify current VHA employees.
Meet the grade-specific experience or education requirements and demonstrated knowledge, skills, and abilities for the grade selected.
Knowledge of applicable classification systems, including ICD, CPT, and HCPCS, for the GS-7 criteria.
Ability to communicate effectively in writing and verbally, use data collection and analytical techniques, use computer applications to produce reports and analyze data, work independently, adapt to shifting priorities, and meet deadlines, for the GS-7 criteria.
For GS-9 criteria, knowledge of medical and legal HIM requirements; ability to advise on HIM practices; skill extracting and analyzing data and preparing reports; ability to interpret and apply HIM guidelines; and knowledge of process improvement techniques.
For GS-11 criteria, skill in performance and process improvement; ability to advise on documentation and HIM practices; ability to plan, evaluate, monitor, and recommend changes to processes and policies; ability to assess compliance with legal, ethical, regulatory, and accreditation requirements; and ability to transform data into meaningful information.
Register with Selective Service if applicable to males born after December 31, 1959.
Complete a background/security investigation and online onboarding, provide acceptable identification, and participate in the VA seasonal influenza vaccination program.
Serve a one- or two-year trial period, subject to written certification for continued employment.
Meet applicable education requirements using degrees recognized by the U.S. Department of Education from accredited institutions.

Responsibilities

Serve as an HIM technical specialist and provide advice on documentation, coding, confidentiality, release of information, and related requirements.
Research and coordinate projects and studies; develop study plans and tools; analyze data; make recommendations; and prepare management reports.
Analyze HIM processes, workflows, and record review systems, and recommend or implement improvements.
Assist in developing and maintaining health information policies and procedures in compliance with applicable standards and regulations.
Conduct health record reviews and quality assurance studies to assess documentation accuracy, timeliness, completeness, and compliance.
Compile, review, abstract, retrieve, analyze, and interpret medical, legal, clinical, workload, and statistical data.
Assure accurate and timely patient service charge and workload capture by reviewing documentation, encounter data, registration information, and charge records.
Coordinate CPT/HCPCS coding and Charge Description Master updates; validate clinical and encounter data; audit charge reports; and facilitate correction of related issues.
Serve as a liaison for EHR and automated clinical applications; test software and patches, troubleshoot functional issues, and submit work orders or Remedy tickets.
Provide technical assistance with HIM software and computer applications, including coding, release of information, dictation, speech recognition, forms, templates, and EHR functions.
Review requests for new or revised templates and forms and assist with implementation.
Coordinate health record corrections and work with clinical staff to resolve incomplete, inconsistent, or improperly identified documentation.
Train HIM, clinical, and administrative staff on HIM, documentation, coding, EHR functionality, privacy, release of information, revenue cycle processes, and emerging technologies.
Assist HIM leadership with program goals, quality improvement initiatives, presentations, audits, performance monitoring, and short- and long-range planning.
Participate in facility, VISN, and national committees and collaborate with relevant program, finance, medical center, and charge services teams.