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. The Health Information Manager also creates and monitors systems to ensure accurate, timely, and complete health records, in accordance with VHA policy and The Joint Commission 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 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.
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, 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. Establishes monitors to ensure the timeliness of hard-copy and/or electronic health record entries and reports findings with subsequent trending of data. Provides management officials hard copy and/or electronic health record review results and trends on an ongoing basis. Maintains and reports delinquent records by number, type of deficiencies and responsible provider. Incumbent serves as a resource for patient data on both patient-specific and aggregate databases. Represents HAS 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, The Joint Commission standards, record retrieval processes, health record components, systems, goals, electronic records, etc.
The CHIM at this level has the full complement of HIMS supervisory responsibility including coding, file room, scanning, release of information, and transcription. Oversees the facility Records Manager. Incumbent is responsible for directing the operations of all personnel working within the Health Information program and is regularly involved in labor relations and budget management. Performs the administrative and personnel management functions relative to staff supervised. Establishes guidelines and performance expectations for staff, which are clearly communicated through the formal employee performance management system. Observes workers' performance; demonstrates and conducts work performance critiques. Provides informal feedback and periodically evaluates employee performance. Resolves informal complaints and grievances. Develops work improvement plans, recommending personnel actions as necessary. Provides advice and counsel to workers related to work and administrative matters. Effects disciplinary measures as appropriate to the authority delegated in this area. Reviews and approves leave requests.
Work Schedule: Monday- Friday 7:30am-4:00pm
Telework: Available
Virtual: This is not a virtual position.
Functional Statement #: 000000
Relocation/Recruitment Incentives: Authorized
Permanent Change of Station (PCS): May Be Authorized
Starting at $90,662 Per Year (GS 12)
