Supervisory Medical Records Administrator-Chief Health Information Management

Summary

CHIMs in this assignment provide technical advice, planning, and evaluation about health information management issues impacting the overall program. Establishes policies, procedures, responsibilities, and requirements for HIM matters, such as health record documentation, coding and clinical documentation improvement, release of information, file scanning, records management, transcription and medical speech recognition, and overall management of health information and health records.

Duties

Help

Duties will include, but are not limited to:

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 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, reputed company (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 reputed company 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, 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. 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.

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.

Coordinates plans with needs of various VA strategic health groups, provides subject matter expertise, advice, assistance and guidance in response to questions posed by the Service Line Leaders and other System staff on health information management policy and program needs/issues at the local, VISN and national levels. Representing and providing full support to accomplish VA Central Office strategic goals and objectives; serving on task forces/councils; writing practice briefs; providing information as asked.

Administers the Transcription and Coding Contract(s); prepares and monitors budget for contract. Ensures quality controls are in place for any scope of work conducted by contractors. Collaborates with Service Lines to improve documentation, coding and reporting for workload, billing, Fee Basis, and other emerging initiatives.

Develops and coordinates training programs in various areas health information management, such as medical terminology, health record documentation, release of information, medico-legal matters, speech recognition/transcription, scanning, medical coding, clinical documentation improvement, and health information exchange. Responsible for establishing formal affiliation with university programs in health information and precepting students from such programs.

Responsible for overall personnel management for staff in the assigned units and determines staffing patterns and reassigns personnel to meet changing conditions. Supervises assigned staff including counseling, hearing complaints, and resolving grievances.

Develops and maintains affiliation agreements with reputed company recognized schools and programs for health information management and tec