Medical Records Administrator

Veterans Health Administration • San Diego, CA

9d • Onsite

About The Position

This position serves as the Assistant Chief of Health Information Management (HIM), assisting the Chief HIM in establishing policies, responsibilities, and requirements for health information management matters. These include health record documentation, coding and clinical documentation improvement, records management, release of information, file room and scanning, transcription and medical speech recognition, and management of health information and Veterans’ health records.

The incumbent has technical and administrative responsibility for daily HIM department operations, including coding, health record documentation analysis, transcription and speech recognition, release of information, file room and scanning programs, and health information exchange. The role provides expertise, guidance, supervision, administrative support, coordination, and technical assistance in planning, developing, and maintaining an effective, comprehensive, and integrated HIM program. The incumbent assists the Chief HIM with planning, directing, policymaking, organizing, and controlling department activities, and serves as Acting Chief HIM in the Chief’s absence.

The position shares responsibility for collecting and processing data for reports, surveys, and research; preparing reports and recommendations for management; identifying equipment and staffing needs; and maintaining procedures and operating manuals. It supports research by helping health professionals access health record information while protecting confidentiality, and screens, abstracts, and tallies information from records and computer-generated reports. The incumbent audits and monitors areas of responsibility and assesses employee work for quality, quantity, accuracy, and timeliness.

The role carries out personnel functions, including establishing performance standards, interviewing candidates, recommending selections, training and developing employees, recommending awards or disciplinary action, approving leave, and establishing work schedules. It also supports other HIM supervisors and leads with employee selection, training, and evaluation, and provides technical guidance and coverage to units when supervisors are absent.

The incumbent advises on subpoenas, court orders, advance directives, release of information, and other medico-legal issues. The position prepares training materials and participates in orientation and instruction for clerical staff, physicians, house staff, and other members of the healthcare team. Training may cover medical terminology, health record documentation requirements, release of information, the Privacy Act, and HIPAA. The incumbent participates in health record reviews and ensures review activities comply with VA handbooks and directives, TJC standards and scoring guidelines, CARF, Behavioral Health, and OIG requirements.

The position also assists with planning, developing, directing, and evaluating health information and related functions, and applies skills in budgeting, contracting, procurement, and property management. Work schedule: Monday through Friday, 8:00 a.m. to 4:30 p.m. The work is sedentary, with occasional walking, standing, bending, carrying light items, or driving; no special physical demands are required.

Requirements

• U.S. citizenship, except where appointment of a non-citizen is permitted under VA policy when qualified citizens cannot be recruited.
• Proficiency in written and spoken English.
• Three years of creditable medical-records experience involving preparation, maintenance, and management of health records and health information systems, including relevant knowledge of medical terminology, records procedures, coding, or healthcare administrative and legal requirements; or a qualifying education or education-and-experience combination.
• Alternatively, a bachelor’s degree or higher from an accredited institution in health information management or a related degree with at least 24 semester hours in health information management or health information technology; or an equivalent combination of education and experience.
• HIM certification through AHIMA or AAPC.
• For GS-12: one year of creditable experience equivalent to the next lower grade level and a HIM certification.
• Ability to manage projects and processes and develop new or improved solutions to complex HIM technical problems.
• Ability to advise management and staff on health information management practices based on current industry standards, policies, statutes, laws, and regulations.
• Ability to plan, justify, develop, evaluate, assess, monitor, and advise on HIM processes and recommend policy or procedure changes.
• Ability to evaluate compliance with legal, ethical, regulatory, and accrediting-body guidelines applicable to HIM.
• Ability to apply sound resource-management principles, including staffing, space, contracts, and equipment.
• Ability to perform supervisory duties, including assigning work, completing performance evaluations, selecting staff, and recommending awards, advancements, and disciplinary actions.
• Must complete a background/security investigation, pre-employment physical examination, and online onboarding process; provide acceptable identification and meet application-document requirements.
• Must participate in the seasonal influenza vaccination program.
• Must serve a one- or two-year trial period, subject to evaluation and written certification for continued employment.
• Selective Service registration is required for males born after December 31, 1959.

Responsibilities

• Assist the Chief of Health Information Management in establishing policies, responsibilities, and requirements for HIM matters.
• Manage the daily technical and administrative operations of the HIM department, including coding, documentation analysis, transcription and speech recognition, release of information, file room and scanning programs, and health information exchange.
• Assist with planning, directing, policymaking, organizing, and controlling department activities; serve as Acting Chief HIM in the Chief’s absence.
• Provide expertise, guidance, supervision, administrative support, coordination, and technical assistance for the HIM program.
• Collect and process data for reports, surveys, and research projects; prepare reports and recommendations for management.
• Recommend equipment and staffing needs and prepare and maintain procedures and operating manuals.
• Assist health professionals in obtaining health record information for research while protecting record confidentiality.
• Screen, abstract, and tally data from records and computer-generated reports.
• Audit and monitor areas of responsibility and assess employee work for quality, quantity, accuracy, and timeliness.
• Develop and conduct competency assessments and carry out personnel functions, including setting performance standards, interviewing candidates, recommending selections, training employees, recommending awards or disciplinary action, approving leave, and establishing schedules.
• Support HIM supervisors and leads in selecting, training, and evaluating employees; provide technical guidance and coverage to units when supervisors are absent.
• Provide expertise on subpoenas, court orders, advance directives, release of information, and other medico-legal matters.
• Prepare training materials and participate in orientation and instructional activities for clerical staff and healthcare professionals.
• Advise management and hospital staff on policies, procedures, record-content adequacy, and training of clerical personnel.
• Participate in health record review activities and ensure reviews comply with applicable VA, TJC, CARF, Behavioral Health, and OIG requirements.
• Assist in planning, developing, directing, and evaluating health information and related functions.
• Apply resource-management skills in budgeting, contracting, procurement, and property management.

Benefits

• Federal employee benefits package; eligibility and specific benefits depend on position type and should be confirmed with the hiring agency.
• Potential credit toward annual leave accrual based on prior work or military service, subject to request and approval before appointment.

What This Job Offers

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