The CHIM establishes policies, procedures, responsibilities, and requirements for HIM- related matters, such as health record documentation, coding and clinical documentation improvement, release of information, file room/scanning, records management, transcription and medical speech recognition, as well as the overall management of health information and Veterans health records.
Applicants pending the completion of educational or certification/licensure requirements may be referred and tentatively selected but may not be hired until all requirements are met. Basic Requirements: Citizenship: Be a citizen of the United States. (Non-citizens may be appointed when it is not possible to recruit qualified citizens in accordance with chapter 3, section A, paragraph 3g this part) English Language Proficiency: Candidates must be proficient in spoken and written English to be appointed as authorized by 38 U.S.C. § 7403(f). Education or Experience: (1) Experience: Three years of [creditable] experience in the field of medical records that included the preparation, maintenance, and management of [health] records and health information systems [demonstrating a knowledge of medical terminology,] medical records [procedures, medical coding, or medical, administrative, and legal requirements of health care delivery] systems. OR (2) Education: Successful completion of a bachelor's degree or higher from an accredited college or university [recognized by the U.S. Department of Education], with a major field of study in health information management, or a related degree with a minimum of 24 semester hours in health information management or health information technology. OR (3) Experience/Education Combination: Equivalent combinations of [creditable] experience and education that equals 100 percent may be used to meet basic requirements. [For example, two years above high school from an accredited college or university, with 12 semester hours in health information technology/health information management, plus one year and six months of creditable experience that included the preparation, maintenance, and management of health records and health information systems meets an equivalent combination. Certification: Persons hired or reassigned to MRA positions in the GS-0669 series in VHA must meet one of the following: (1)Coding Certification through AHIMA or AAPC. NOTE. See paragraph 2a above for a detailed definition of Coding Certification. OR, (2) HIM Certification through AHIMA. NOTE. See paragraph 2d above for a detailed definition of HIM Certification. OR, (3) Health Data Analyst Certification through AHIMA. NOTE. See paragraph 2c above for a detailed definition of Health Data Analyst Certification. NOTE. HIMs Certification is required for all positions above the full performance level. May qualify based on being covered by the Grandfathering Provision as described in the VA Qualification Standard for this occupation (only applicable to current VHA employees who are in this occupation and meet the criteria). Grade Determinations: Medical Records Administrator (Chief (CHIM)), GS-12 Experience: One year of creditable experience equivalent to the next lower grade level that demonstrates the KSAs described at that level. AND Certification: Employees at this level must have a HIM Certification NOTE. See paragraph 2d of this appendix for detailed definitions of HIM Certification. AND Demonstrated Knowledge, Skills, and Abilities: Ability to determine and evaluate compliance with legal, ethical, and regulatory guidelines and accrediting bodies, as they apply to health information management. Skill in evaluating, developing, and implementing new policies, procedures, and programs. Ability to provide program oversight, including advisory and technical expertise on a range of health information management practices and guidelines to staff at various levels. Ability to develop and conduct training on health information management programs, policies, procedures, and performance improvement activities. Ability to effectively procure and manage HIM resources (i.e. space, staffing, education, budget, etc.). Ability to provide the full range of supervisory duties to include assignment of work; completing performance evaluations; selection of staff; and recommendation of awards, advancements, and disciplinary actions. Customer service skills necessary to effectively communicate (written and verbal) and interact with all levels of hospital personnel, physicians, patients, and outside agencies. Ability to deal effectively with sensitive and/or complex situations. Reference: For more information on this qualification standard, please visit https://www.va.gov/ohrm/QualificationStandards/. The full performance level of this vacancy is GS-12. The actual grade at which an applicant may be selected for this vacancy is GS-12. Physical Requirements: See VA Directive and Handbook 5019.
Serves as Chief of Health Information Management (CHIM) 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 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 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. Completes internal quality assurance reviews to ensure employee performance and that work meets quality and quantity standards. Establishes monitors to ensure the timeliness of health record entries and reports findings with subsequent trending of data. Provides management officials with health record review results and trends on an ongoing basis. Monitors and reports delinquent records by number, type of deficiencies and responsible provider. Serves as a resource for patient data on both patient-specific and aggregate databases. Represents Healthcare Administration Service and acts as subject matter expert at the facility-wide Health Records Committee. In this capacity, the incumbent advises the committee on health record issues; including VA requirements, TJC standards, record retrieval processes, health record components, systems, goals, electronic records, etc. Health information is an integral part of TJC standards and excellent health information management is essential for the facility to maintain its standing as a fully accredited institution. All aspects of risk management depend upon health information and its documentation. The incumbent is a key member of the Quality Improvement (QI) team, works closely with QI personnel, and is responsible for assuring that the facility is compliant with all TJC standards regarding health information. 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. Work Schedule: 0800 - 1630, Monday - Friday (As Determined by the Service) Telework: Available (Ad-Hoc) Virtual: This is not a virtual position. Functional Statement #: 57913-O Relocation/Recruitment Incentives: Authorized Permanent Change of Station (PCS): Authorized PCS Appraised Value Offer (AVO): Not Authorized