Medical Records Administration Specialist

About the role

Medical Records Administrators (MRAs) for the William Jennings Bryan Dorn VA Health Care System perform work concerned with the management of a health record program or the provision of services related to medical record administration/health information services. MRAs manage, preserve, analyze, and supervise the use of diagnostic and therapeutic health records/health information management.

Responsibilities

• Assist the Chief of Health Information Management services in identifying and setting short and long-range goals, program objectives, and tasks.
• Provides subject matter expertise to Service Line Leaders related to health records and records information management.
• Interprets The Joint commission standards, VHA regulations, and Medical center policies and ensures that the HIM service is following these regulatory practices.
• Provides training for HIM, clinical, and administrative staff on HIM topics and policy changes/updates.
• Designs and performs quality improvement projects regarding HIM issues.
• Keeps HIM and clinical staff abreast of changing technology in electronic systems used to collect, process, code, protect, and store health information.
• Performs audits and analyses, preparing and presenting findings and recommendations to the Chief of HIM as well as medical center staff.
• Reviews, analyzes, and reports HIM performance monitors.
• Advises Principal Investigators and other clinical staff on methodologies related to retrieval of health care data for specific studies.
• Utilizes advanced knowledge of VHA data sources to complete analyses of VA Medical Center data.
• Interacts with clinical/ancillary staff to ensure that charge order items, represented by HCPCS/CPT codes, accurately reflect services provided.
• Collaborates on improperly identified documents with clinicians, Clinical Applications Coordinators, and others who report problems.
• Reassigns, rescinds, and removes documents when they have been entered or uploaded incorrectly.
• Provides education when dealing directly with clinical providers requesting completion or adjustment of pertinent parts of incomplete or inconsistent health records.
• Serves as the facility expert for software and computer applications related to HIM to provide technical assistance to HIM staff.
• Serves as the point of contact for health record corrections to ensure documentation accurately reflects care delivered and reported.
• May review and test HIM related software patches and updates.
• Tests and troubleshoots EHR menu options and functional issues when HIM users report application errors.
• Performs equipment needs analysis for new or replacement equipment and/or equipment repair.
• Facilitates correction of clinical documentation issues that result in encounter charge errors.
• Facilitates correction of clinical documentation issues that result in encounter charge errors.
• Performs other necessary duties as assigned.

Requirements

This job is open to current permanent Department of Veteran Affairs employees, current permanent Federal employees of other agencies and all US Citizens.

Major duties may include (but are not limited to):

• Assist the Chief of Health Information Management services in identifying and setting short and long-range goals, program objectives, and tasks.
• Provides subject matter expertise to Service Line Leaders related to health records and records information management.
• Interprets The Joint commission standards, VHA regulations, and Medical center policies and ensures that the HIM service is following these regulatory practices.
• Provides training for HIM, clinical, and administrative staff on HIM topics and policy changes/updates.
• Designs and performs quality improvement projects regarding HIM issues.
• Keeps HIM and clinical staff abreast of changing technology in electronic systems used to collect, process, code, protect, and store health information.
• Performs audits and analyses, preparing and presenting findings and recommendations to the Chief of HIM as well as medical center staff.
• Reviews, analyzes, and reports HIM performance monitors.
• Advises Principal Investigators and other clinical staff on methodologies related to retrieval of health care data for specific studies.
• Utilizes advanced knowledge of VHA data sources to complete analyses of VA Medical Center data.
• Interacts with clinical/ancillary staff to ensure that charge order items, represented by HCPCS/CPT codes, accurately reflect services provided.
• Collaborates on improperly identified documents with clinicians, Clinical Applications Coordinators, and others who report problems.
• Reassigns, rescinds, and removes documents when they have been entered or uploaded incorrectly.
• Provides education when dealing directly with clinical providers requesting completion or adjustment of pertinent parts of incomplete or inconsistent health records.
• Serves as the facility expert for software and computer applications related to HIM to provide technical assistance to HIM staff.
• Serves as the point of contact for health record corrections to ensure documentation accurately reflects care delivered and reported.
• May review and test HIM related software patches and updates.
• Tests and troubleshoots EHR menu options and functional issues when HIM users report application errors.
• Performs equipment needs analysis for new or replacement equipment and/or equipment repair.
• Facilitates correction of clinical documentation issues that result in encounter charge errors.
• Facilitates correction of clinical documentation issues that result in encounter charge errors.
• Performs other necessary duties as assigned.

Qualifications

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:

• United States Citizenship: Non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy.
• Education or Experience:
• 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,
• 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,
• 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:

• Coding Certification through AHIMA or AAPC. OR,
• HIM Certification through AHIMA. OR,
• Health Data Analyst Certification through AHIMA.

Grandfathering Provision: All persons employed in VHA as an MRA are considered to have met all qualification requirements for the title, series, and grade held, including positive education, and registration and/or certification that are part of the basic requirements of the occupation. For employees who do not meet all the basic requirements in this standard, but who met the qualifications applicable to the position at the time they were appointed, the following provisions apply:

• Such employees may be reassigned, promoted up to, and including, the full performance ([journeyman]) level, or changed to lower grade within the occupation, but may not be promoted beyond the [journeyman] level or placed in supervisory or managerial positions.
• Employees who were appointed on a temporary basis, prior to the effective date of the qualification standard, may not have their temporary appointment extended or be reappointed on a temporary or permanent basis until they fully meet the basic requirements of the standard.
• Employees initially grandfathered into this occupation who subsequently obtain additional education and/or licensure/registration/certification, and meet all the basic requirements of this qualification standard, must maintain the required credentials as a condition of employment in the occupation.
• MRAs who are converted to title 38 hybrid status under this provision and subsequently leave the occupation lose protected status and must meet the full VA qualification standard requirements in effect at the time of reentry, as a medical records administrator.

GS 11 Grade Determinations:

• Experience/Education:
• One year of creditable experience equivalent to the next lower grade level GS9 that demonstrates all the KSAs described at that level.
• Education equivalent to three full years of progressively higher-level graduate education or a Ph.D., or equivalent doctoral degree from an accredited university or college in the field of health information management.
• Demonstrated Knowledge, Skills, and Abilities (KSAs):
• Skill in performance and process improvement [techniques to develop and implement new or improved solutions in health information management.
• Ability to advise management and staff, at various levels, regarding health record documentation requirements and health information management practices based on current industry standards, policies, statues, laws, and regulations.
• Ability to plan, justify, develop, evaluate, assess, monitor, and advise on current health information management processes and recommend changes in policies or procedures.
• Ability to determine and evaluate compliance with legal, ethical, and regulatory guidelines and accrediting bodies, as they apply to health information management.
• Ability to acquire, manage, analyze, interpret, and transform data into accurate, consistent, and meaningful information.