Duties
This position is located in the Health Information Management (HIM) section of Health Administration Service (HAS) at the Salisbury VA Health Care System, Salisbury, NC. Medical Records Administrators (MRAs) in VHA perform or supervise work concerned with the management of a health record program or the provision of service related to medical record administration/ health information services.
Duties include but are not limited to: This position is located in the Health Information Management (HIM) Section of Health Administration Service (HAS) at the Salisbury VA Health Care System. 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.
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, HAS 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.
Work is of an analytical, evaluative, and creative nature, and incumbent is responsible for keeping abreast of constant changes in the health information field as well as allied health fields and applying the information and knowledge gathered to the operations of the hospital.
Incumbent assists the CHIM in the effective administration and planning of HIM program throughout all areas of the facility to provide maximum support to staff in the treatment of patients and the facility's research programs. Activities must be accomplished in compliance with appropriate directives and requirements of VA/VHA Regulations, Medical Center Memoranda, and accreditation requirements such as The Joint Commission (TJC) and the Commission on Accreditation of Rehabilitation Facilities (CARF) standards.
Participates in various facility, VISN and national committees requiring HIM subject matter expertise. Prepares reports and presents data to the committee(s). Responsible for developing and updating policies pertaining to committee functions, health record reviews, and HIM activities. Ensures that health record review activities are consistent with the requirements established by VHA handbooks, program guides, fact sheets, and directives, and are in compliance with TJC standards and Scoring Guidelines, CARF, Behavioral Health, and the Office of Inspector General (OIG). Advises committees, management and staff on adequate health record documentation, health information services, and EHR practices based on current policies, regulations, and industry standards. May coordinate Medical/Health Record Committee (or equivalent) meetings. Assists in coordinating/completing routine and non-routine reports. Assists physicians and other health care professionals with research projects and education related to VHA HIM processes/procedures.
Work Schedule
Monday - Friday 8am - 4:30pm
Telework
Not Available
Virtual
This is not a virtual position.
Relocation/Recruitment Incentives
Not Authorized
Permanent Change of Station (PCS)
Not Authorized
Requirements
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