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Major Duties:
Official account of Jobstore.
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 standards, the Commission on Accreditation of Rehabilitation Facilities (CARF), and other regulatory and accrediting agencies.
Responsible for all facets of health records management for the facility ensuring 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, research, and facilitate performance improvement processes and legal requirements. Develops policies, processes, and procedures that address all VA, Federal, regulatory, and accrediting requirements for HIM.
Must provide detailed technical expertise in health records science and other very technical aspects of health information. 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 The Joint Commission and is consistent with professional health records standards.
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, patient privacy and confidentiality, etc. Recommends improvements in documentation used to provide patient care, to optimize VERA workload, third party reimbursement and to manage resources. Completes internal quality assurance reviews to ensure employee performance and that work meets quality and quantity standards
Responsible for assuring that all patients have a complete, accurate, and timely record of their medical care at the facility. Also must assure that such information is appropriately stored and readily available for the provision of medical services to the patients.
Responsible for maintenance and evaluation of health records, and assuring legal requirements for care are met. Performs these duties as the facility expert but does not involve substantial line responsibility for establishing and implementing overall clinical policies.
Plays a central role in developing and coordinating internal review systems to assure that both clinical and administrative activities are in compliance with agency and accrediting and regulatory requirements.
Work Schedule: Monday - Friday / 0800 - 1630
Telework: Available
Virtual: This is not a virtual position.
Functional Statement #: Medical Records Administrator (CHIM)
Relocation/Recruitment Incentives: Not Authorized
Permanent Change of Station (PCS): Not Authorized
Financial Disclosure Report: Not required
Official account of Jobstore.