Medical Records Administration Specialist – US Department of Veterans Affairs – Sheridan, WY

Major Duties:
Serves as the Chief of Health Information Management Section with full program responsibility for all facets of the Health Information Management (HIM) program and processes. Must ensure HIM program meets and/or exceed national HIM policies, procedures, and performance metrics. Responsible for the administrative management of health records, which includes planning, managing, advising, and directing the health information program in accordance with applicable Federal laws, facility by-laws, VHA policy, The Joint Commission (TJC) standards, the Commission on Accreditation of Rehabilitation Facilities (CARF), and other regulatory and accrediting agency standards. Creates and monitors systems to ensure accurate, timely, and complete health records, in accordance with VHA policy and TJC health information protocols. Measures ongoing intradepartmental performance by establishing priorities, collecting data, monitoring and reporting outcomes, using valid and reliable techniques to analyze trends and variation, and taking appropriate action based on findings.

Responsible for all facets of health records management for the facilityensuring maintenance of complete, accurate, timely, clinically-pertinent, and readily-accessible patient health records, which contain sufficient recorded information to serve as a basis to plan patient care, support diagnoses, warrant treatment, measure outcomes, support education and facilitate performance improvement processes and legal requirements. Develops policies, processes, and procedures that address all VA, Federal, regulatory, and accrediting requirements for HIM. Evaluates health records program and independently determines the nature and extent of problem areas. Develops recommendations and solutions for program improvement. Develops and implements innovative solutions to correct technical, complex problems.

Must provide detailed technical expertise in health records science and other very technical aspects of HIM. Maintains all health information input into the local VistA database and assures timely transmission of that data into all VA centralized databases – most frequently those maintained at the Austin Data Processing Center. Must assure that all health information that is coded and abstracted meets the requirements of the VA and/or TJC and is consistent with professional health records standards.

Clinical support role: The incumbent is a key advisor to the Chief of Staff, Executive Management, and clinicians and is responsible for providing technical guidance on health information issues such as documentation requirements, liability issues, advance directives, informed consent, release of information, transcription/speech recognition, health information exchange, etc. Recommends improvements in health record documentation used to provide patient care, to optimize VERA workload, third party reimbursement and to manage resources.

Responsible for assuring that all patients have a complete, accurate, and timely record of their health care at the facility. Must assure that such information is appropriately stored and readily available for the provision of medical services to the patients.

Incumbent is directly responsible to the Chief Business Officer who gives general objectives.

Incumbent exercises independent judgment in carrying out duties and responsibilities and has complete authority to plan, design and direct the HIM program; recommendations and/or technical decisions made by employee are not reviewed. Employee operates within context of overall agency policy and agency goals. Supervision is performed in relation to outcome and accomplishment to policy requirements.

Work Schedule: M-F, 7:30 A.M. to 4:00 P.M.
Financial Disclosure Report: Not required
Recruitment/Relocation Incentives Authorized: Yes, 15% incentive payment for two years.

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