Medical Records Administrator (Chief (CHIM))

Veterans Health Administration • Montrose, NY

5d • Onsite

About The Position

The Hudson Valley VA Healthcare System is hiring one Medical Records Administrator (Chief of CHIM) at the Montrose VAMC in Health Administrative Service. The incumbent manages, preserves, analyzes, and supervises the use of diagnostic and therapeutic health records and health information management. This role leads the facility’s health information management (HIM) program and its services, ensuring compliance with applicable federal law, facility bylaws, VA policies, and regulatory and accrediting standards. The position has supervisory responsibility across coding, record completion, file room, scanning, release of information, and transcription functions, with a mix of HT38 and Title 5 positions.

The Medical Records Administrator oversees the accuracy, completeness, timeliness, clinical relevance, and accessibility of patient health records. The role develops and monitors systems, policies, processes, and procedures; evaluates program performance and identifies improvement opportunities; and provides technical expertise and guidance on health records science and HIM practices. The incumbent maintains health information in the local VistA database and ensures timely transmission to VA centralized databases, including those maintained at the Austin Data Processing Center. The position also provides training, coordinates student affiliations and preceptorships, advises management officials on review findings and trends, and coordinates internal reviews to support clinical and administrative compliance.

The position is full-time, Monday through Friday, 8:00 a.m. to 4:30 p.m. It is eligible for ad-hoc telework with supervisor approval and is not a virtual position. Employees must complete a one- or two-year trial period. VA employees receive a federal benefits package; specific benefits eligibility depends on position and employment status.

Requirements

• U.S. citizenship, subject to the stated exception for non-citizens when qualified candidates cannot be recruited under applicable law.
• Proficiency in spoken and written English.
• Either three years of creditable medical records experience involving health-record preparation, maintenance, and management and health information systems, with knowledge of medical terminology, medical records procedures, medical coding, or healthcare delivery requirements; a qualifying bachelor’s degree or higher in health information management or a related field with at least 24 semester hours in HIM or health information technology; or an equivalent combination of education and experience.
• A qualifying certification for MRA positions: coding certification through AHIMA or AAPC, HIM certification through AHIMA, or Health Data Analyst certification through AHIMA. HIM certification is required for positions above the full-performance level.
• One year of creditable experience equivalent to the next lower grade level for the GS-12 grade determination.
• HIM certification for the GS-12 level.
• Ability to determine and evaluate compliance with legal, ethical, regulatory, and accrediting guidelines as they apply to HIM.
• Skill in evaluating, developing, and implementing policies, procedures, and programs.
• Ability to provide program oversight and advisory and technical expertise on HIM practices and guidelines to staff at various levels.
• Ability to develop and conduct training on HIM programs, policies, procedures, and performance improvement activities.
• Ability to procure and manage HIM resources, including space, staffing, education, and budget.
• Ability to perform the full range of supervisory duties, including assigning work, completing performance evaluations, selecting staff, and recommending awards, advancements, and disciplinary actions.
• Customer service and written and verbal communication skills to interact effectively with hospital personnel, physicians, patients, and outside agencies.
• Ability to handle sensitive and/or complex situations.
• Maintain required credentials through continuing education.
• Meet applicable physical requirements described in VA Directive and Handbook 5019.
• Complete required background/security investigation, onboarding, identification, and application documentation; participate in the seasonal influenza vaccination program.
• Serve a one- or two-year trial period as a condition of employment.

Responsibilities

• Ensure the HIM program meets or exceeds national HIM policies, procedures, and performance metrics.
• Plan, manage, advise, and direct the health information program in accordance with federal laws, facility bylaws, VA policy, Joint Commission standards, CARF standards, and other applicable regulatory and accrediting requirements.
• Create and monitor systems to ensure health records are accurate, timely, complete, and compliant with VA policy and health information protocols.
• Measure intradepartmental performance by setting priorities, collecting data, monitoring and reporting outcomes, analyzing trends and variation, and taking appropriate action.
• Oversee facility health records management to ensure patient records are complete, accurate, timely, clinically pertinent, accessible, and sufficient to support care planning, diagnoses, treatment, outcomes measurement, education, performance improvement, and legal requirements.
• Develop policies, processes, and procedures addressing VA, federal, regulatory, and accrediting requirements for HIM.
• Evaluate the health records program, identify problem areas, and develop recommendations and solutions for program improvement.
• Provide technical expertise in health records science and other technical aspects of HIM.
• Maintain health information in the local VistA database and ensure timely transmission to VA centralized databases, including the Austin Data Processing Center.
• Ensure coded and abstracted health information meets VA and/or Joint Commission requirements and professional health records standards.
• Recommend improvements to health record documentation to support patient care, optimize VERA workload, third-party reimbursement, and resource management.
• Provide management officials with ongoing health record review results and trend information.
• Monitor and report delinquent records, including counts, deficiency types, and responsible providers.
• Ensure every patient has a complete, accurate, and timely record of care at the facility.
• Conduct training in areas such as medical terminology, health record documentation, release of information, medico-legal matters, speech recognition/transcription, scanning, medical coding, clinical documentation improvement, and health information exchange.
• Establish formal affiliations with university health information programs and precept students from those programs.
• Supervise coding, record completion, file room, scanning, release of information, and transcription functions.
• Develop work improvement plans and recommend personnel actions as necessary.
• Maintain and evaluate health records and ensure legal requirements for care are met.
• Develop and coordinate internal review systems to ensure clinical and administrative activities comply with agency, accrediting, and regulatory requirements.
• Perform the full range of supervisory duties, including work assignment, performance evaluations, staff selection, and recommendations for awards, advancements, and disciplinary actions.

Benefits

• Federal employee benefits package for eligible employees and their families.
• Potential credit toward annual leave accrual based on prior federal work or military service, subject to request and approval.

What This Job Offers

• Job Type: Full-time
• Career Level: Manager