Medical Records Administrator (Assistant Chief (ACHIM))

Department of Veterans Affairs•Muskogee, OK

34d•Onsite

About The Position

This position is located in the Health Information Management (HIM) Section of the Business Office Service at the Jack C. Montgomery VA Medical Center. Medical Records Administrators (MRAs) in VHA perform or supervise work concerned with the management of a health record program or the provision of services related to medical record administration/health information services. The incumbent serves as the Assistant Chief of Health Information Management (ACHIM) in a medical facility of high complexity (level 1), with responsibility for the supervision of all HIM functions. Incumbent is charged with full responsibility, both technical and administrative, for the daily operation of the HIM department which consists of all functions of health record activities related to medical coding, clinical documentation integrity, health record documentation analysis, transcription/speech recognition, release of information, file room, scanning and indexing, and health information exchange. Is a full assistant to the Chief of Health Information Management (CHIM). Provides expertise, guidance, direction, and has responsibilities relative to providing supervision, administrative support, coordination, and technical assistance in the planning, development and maintenance of an effective, comprehensive, and integrated HIM Program at this Medical Center. This position assists the CHIM in the planning, directing, policy making, organizing and controlling the activities of the HIM department and serves as acting CHIM in the absence of the CHIM. The incumbent shares responsibility with the CHIM for collecting and processing data for various reports, surveys, and research projects; for preparing reports and making recommendations for review and consideration by the Chief, Business Office and upper management concerning the immediate needs as well as the long-term goals of the HIM department; for recommending equipment and staffing needs; and for preparing and updating policies, standard operating procedures, and training guides. Responsible for assisting physicians and other health professionals in obtaining health record information to be used in research projects. Advises on what data is available, how it may be obtained, and the uses that can be made of the information while protecting the confidentiality of the record. The incumbent aids in a variety of projects and is responsible for screening, abstracting and tallying data from health records and computer-generated reports. Serves as a consultant providing guidance and advising researchers on methods for gathering health information and health record data. Assists in retrospective health record review/data abstraction projects to support medical center Quality Management data collection activities. Consistently conducts audits and monitors for all areas of responsibility, ensuring accurate and timely data is processed by all employees. Reviews completed work and assesses quality, quantity, accuracy, and timeliness of work produced by each employee and provides constructive feedback. Ascertains problems encountered, develops performance improvement plans, and recommends personnel actions as necessary. Develops performance standards and conducts performance evaluations. Develops and conducts competency assessments. Responsible for carrying out established personnel functions and practices. Keeps employees informed about important aspects of personnel management programs. Interviews prospective employees, recommends selection, and carries out training and development of assignments, awards or disciplinary action. Approves leave and establishes work schedules ensuring appropriate workload coverage. Implements provisions of EEO programs to ensure fair and equal treatment for all employees. Coordinates monthly staff meetings and prepares timely/accurate minutes. The incumbent prepares training materials and participates in orientation and instructional activities as required. Incumbent advises management and hospital staff members on policies, procedures, and adequacy of health record content, and on training and teaching of administrative personnel in health record functions. Incumbent participates in various health record review activities. Assists the CHIM with the development, evaluation, and updating of standard operating procedures, training guides, and policies. May be required to develop training materials and continuing education programs. Training programs developed and conducted by employee may include medical terminology, health record documentation requirements, medical coding, clinical documentation integrity, transcription/speech recognition, scanning and indexing, release of information, Privacy Act and HIPAA instructions. Assistance is also provided in formal and informal service training and orientation of house staff as well as other members of the health care team regarding health record functions and quality.

Responsibilities

Supervision of all HIM functions.
Full responsibility, both technical and administrative, for the daily operation of the HIM department which consists of all functions of health record activities related to medical coding, clinical documentation integrity, health record documentation analysis, transcription/speech recognition, release of information, file room, scanning and indexing, and health information exchange.
Provides expertise, guidance, direction, and has responsibilities relative to providing supervision, administrative support, coordination, and technical assistance in the planning, development and maintenance of an effective, comprehensive, and integrated HIM Program at this Medical Center.
Assists the CHIM in the planning, directing, policy making, organizing and controlling the activities of the HIM department and serves as acting CHIM in the absence of the CHIM.
Shares responsibility with the CHIM for collecting and processing data for various reports, surveys, and research projects; for preparing reports and making recommendations for review and consideration by the Chief, Business Office and upper management concerning the immediate needs as well as the long-term goals of the HIM department; for recommending equipment and staffing needs; and for preparing and updating policies, standard operating procedures, and training guides.
Responsible for assisting physicians and other health professionals in obtaining health record information to be used in research projects.
Aids in a variety of projects and is responsible for screening, abstracting and tallying data from health records and computer-generated reports.
Serves as a consultant providing guidance and advising researchers on methods for gathering health information and health record data.
Assists in retrospective health record review/data abstraction projects to support medical center Quality Management data collection activities.
Consistently conducts audits and monitors for all areas of responsibility, ensuring accurate and timely data is processed by all employees.
Reviews completed work and assesses quality, quantity, accuracy, and timeliness of work produced by each employee and provides constructive feedback.
Ascertains problems encountered, develops performance improvement plans, and recommends personnel actions as necessary.
Develops performance standards and conducts performance evaluations.
Develops and conducts competency assessments.
Responsible for carrying out established personnel functions and practices.
Keeps employees informed about important aspects of personnel management programs.
Interviews prospective employees, recommends selection, and carries out training and development of assignments, awards or disciplinary action.
Approves leave and establishes work schedules ensuring appropriate workload coverage.
Implements provisions of EEO programs to ensure fair and equal treatment for all employees.
Coordinates monthly staff meetings and prepares timely/accurate minutes.
Prepares training materials and participates in orientation and instructional activities as required.
Advises management and hospital staff members on policies, procedures, and adequacy of health record content, and on training and teaching of administrative personnel in health record functions.
Participates in various health record review activities.
Assists the CHIM with the development, evaluation, and updating of standard operating procedures, training guides, and policies.
May be required to develop training materials and continuing education programs.