Medical Records Administration Specialist

Provides subject matter expertise to Service Line Leaders, and medical center staff.

Interprets and applies The Joint Commission (TJC) standards, VHA regulations and medico-legal requirements; current federal codes pertinent to health records; VHA policy memoranda, directives, handbooks and program guides pertinent to health information management; medical coding (ICD, CPT, HCPCS) and reimbursement methodologies; medical and procedural terminology; anatomy and physiology; regulations governing confidentiality of health records; release of information laws and statutes; and all policies/procedures pertaining to VHA health records.

Provides training for HIM, clinical and administrative staff on HIM topics. Designs and performs quality improvement projects regarding HIM issues. Assists the CHIM in preparing and conducting various presentations.

Keeps current on emerging issues and trends in the HIM field, including process improvement initiatives, the electronic health record (EHR), coding and computer-assisted coding, the revenue cycle, release of information and privacy issues, records management, medical speech recognition, transcription and data entry, and health information exchange.

Keeps HIM and clinical staff abreast of changing technology in electronic systems used to collect, process, code, protect and store health information. Participates in various VAMC, VISN and national committees requiring HIM subject matter expertise.

Performs audits and analyses, preparing and presenting findings and recommendations to the CHIM, Service Line Leaders and medical staff. Assures the accuracy and timeliness of the capturing of patient services charges (workload) in accordance with all applicable laws and regulations. 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. Performs data retrieval for special studies as needed.

Utilizes advanced knowledge of VHA data sources, such as VHA Support Service Center (VSSC) and the Corporate Data Warehouse (CDW), to complete analyses of VA Medical Center data. Analyzes and evaluates on a quantitative basis, the effectiveness of the HIM program and operations in meeting established goals and objectives.

Analyzes program performance data to identify areas needing improvement. Serves as point of contact for health record corrections to ensure documentation accurately reflects care delivered and reported. Documentation corrections may consist of retracting erroneous notes, re-titling notes, assigning notes to or removing from consult requests.

Collaborates on improperly identified documents with clinicians, Clinical Applications Coordinators (CACs) and others who report problems. Reassigns, rescinds, and removes documents when they have been entered or uploaded incorrectly.

Provides education when dealing directly with physicians, nurses and other clinical providers requesting completion or adjustment of pertinent parts of the health records, which are found to be inconsistent or incomplete upon analysis.

Assists and provides guidance to supporting clinical services to capture required medical information on patients for computer database input. Selects, compiles and trends medical, surgical, and statistical data from numerous components of the health record.

Retrieves diagnostic and statistical data for various reports required locally or by VISN or VHA Central Office. Work Schedule: Monday - Friday, 7:30am - 4:00pm Telework: Available on an ad-hoc basis. Virtual: This is not a virtual position.

Functional Statement #: 61528-0 / 61529-0 / 61530-0 / 61531-0 Relocation/Recruitment Incentives: Not authorized. Permanent Change of Station (PCS): Not authorized.

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. English Language Proficiency. MRAs must be proficient in spoken & written English. See 38 U.S.C. § 7403(f). Education or Experience.

(1) Experience. 3 years of creditable experience in the field of medical records that included the preparation, maintenance, & management of health records & health information systems demonstrating a knowledge of medical terminology, medical records procedures, medical coding, or medical, administrative, & 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 & education that equals 100% may be used to meet basic requirements.

For example, 2 years above high school from an accredited college or university, with 12 semester hours in health information technology/health information management, plus 1 year & 6 months of creditable experience that included the preparation, maintenance, & management of health records & health information systems meets an equivalent combination.

Creditable Experience. Experience is only creditable if it is in health information management & is directly related to the position to be filled. To be creditable, the candidate's experience must have demonstrated the use of knowledge, skills, & abilities associated with current practice.

Experience satisfying this requirement must be active practice, which is paid/non-paid employment as an MRT/MRA or related field such as medical coding, qualitative & quantitative health record analysis, Health Insurance Portability & Accountability Act privacy & release of information, or preparation, maintenance, & management of health records.

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. OR, (2) HIM Certification through AHIMA. OR, (3) 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, & grade held, including positive education, & registration &/or certification, that are part of the basic requirements of the occupation. Grade Requirements.

In addition to the basic requirements for employment, the following criteria must be met when determining the grade of candidates. Medical Records Administration Specialist, GS-5 None beyond basic requirements. Medical Records Administration Specialist, GS-7 Experience.

In addition to the basic requirements, 1 year of creditable experience equivalent to the next lower grade level (GS-5). OR Education.

Applicants who meet the GS-5 grade level may be appointed at the GS-7 grade level, if they possess a bachelor's degree from an accredited college or university in a major field of study in health information management, with an exemplary academic record as demonstrated by: A 3.0 or higher-grade point average (GPA) out of a possible 4.0 GPA ("B" or better), as recorded on their official transcript or as computed based on four years of education, or as computed based on courses completed during the final 2 years of the curriculum; or A 3.5 GPA or higher out of a possible 4.0 GPA ("B+" or better) based on the average of the required courses completed in the major field of study, or the required courses completed in the major field of study during the final 2 years of the curriculum.

Assignments at the GS-5 level. MRAs are responsible for generating multiple HIM reports. They participate in various health record review activities to ensure the integrity of the health record according to established policies.

Demonstrated Knowledge, Skills, & Abilities (KSAs): Knowledge of current classification systems, such as International Classification of Diseases, Current Procedural Terminology, & the Healthcare Common Procedure Coding System (HCPCS). Ability to effectively communicate (written & verbal) with medical center staff, patients, & external entities.

Ability to use data collection & analytical techniques for purposes of review,quality control, studies & analysis of health information. Ability to utilize computer applications with varied functions to produce a wide range of reports, to abstract records, collect & analyze data & present results in various formats.

Ability to work independently, adapt to shifting priorities, & meet deadlines. Medical Records Administration Specialist, GS-9 Experience. 1 year of creditable experience equivalent to the next lower grade level (GS-7) that demonstrates the knowledge, skills, abilities, & other characteristics described at that level. OR, Education.

Education equivalent to 2 full years of progressively higher level graduate education or a master's degree or equivalent graduate degree from an accredited college or university in a field directly related to health information management. Assignments at the GS7 level.

MRAs are responsible for generating, analyzing, & presenting multiple HIM reports. They monitor health record data integrity per established policies, procedures, & industry standards. They prepare workload & production reports & monitor trends to identify efficiencies & deviations.

Additionally, they participate in various health record review activities. The MRA typically participates in various facility & regional committees requiring health information management subject matter expertise.

Demonstrated Knowledge, Skills, & Abilities (KSAs): Knowledge of medical & legal requirements related to health information management & health records. Ability to provide technical advice & guidance on health information management practices. Skill in extracting data from various sources & analyzing health information to create reports.

Skill in researching, interpreting, & applying health information management guidelines. Knowledge of performance & process improvement techniques to develop new or improved solutions in health information management.

Medical Records Administration Specialist, GS-11 Experience. 1 year of creditable experience equivalent to the next lower grade (GS-9) level that demonstrates all of the KSAs described at that level. OR, Education.

Education equivalent to 3 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 Knowledges, Skills, & Abilities (KSAs): Skill in performance & process improvement [echniques to develop and implement new or improved solutions in health information management.

Ability to advise management & staff, at various levels, regarding health record documentation requirements & health information management practices based on current industry standards, policies, statues, laws, & regulations.

Ability to plan, justify, develop, evaluate, assess, monitor, & advise on current health information management processes & recommend changes in policies or procedures. Ability to determine & evaluate compliance with legal, ethical, & regulatory guidelines & accrediting bodies, as they apply to health information management.

Ability to acquire, manage, analyze, interpret, & transform data into accurate, consistent, & meaningful information.