Medical Records Administration Specialist

This position is in the Health Information Management (HIM) Section of the Health Administration Service (HAS) Service Line at VA Puget Sound Health Care System. Medical Records Administration Specialist (MRAS) in Veterans Health Administration (VHA) perform work concerned with the management of a health record program or the provision of services related to medical record administration/health information services.

Duties listed below are for GS-11 - full performance level, developmental grade will differ in complexity and oversight. They include, but are not limited to: Present findings and recommendations to the Chief of HIM (CHIM) and facility leadership. Perform workflow analyses, recommend process improvements, identify and implement best practices, and implement changes as needed to improve the productivity and quality controls of the HIM department. Prepare workload and production reports, monitor trends to identify efficiencies and outliers, and recommend appropriate actions which may involve collaborating with staff at all levels for resolution. Designs and performs quality improvement projects related to health information management to identify and recommend ways of eliminating, combining, simplifying or improving procedures and processes. Exhibits broad organizational knowledge, communicates and provides training and education to individuals and groups, at multiple levels, both internal and external to the facility. Assists the Chief, Health Information Management (CHIM) and the HIM Department in identifying and setting short and long-range goals, program objectives, and tasks to meet the mission and vision of the VAMC. 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. 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. 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. Performs audits and analyses, preparing and presenting findings and recommendations to the CHIM, Service Line Leaders and medical staff. As a member of the local Revenue Cycle/Charge Services Team, interacts with clinical/ancillary staff to ensure that charge order items, represented by HCPCS/CPT codes, accurately reflect services provided. This includes ensuring charge order items and associated documentation in the health record are accurate, consistent, and reflects the correct service, service date and rendering provider. Establishes and maintains effective working relationships with clinical, informatics, administrative, revenue, and other departments to facilitate expeditious resolution of coding issues related to the functionality of the CDM and related interface processes that causes delays in submission of the data. 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. May assign User Classes to users at the request of the Chief HIM; responds to questions or issues related to that user class. Reviews requests for new templates or additions/correction to existing templates (e.g., clinical reminder dialogs, documentation templates, PowerForms). Reviews requests for new paper forms and assists in the creation and implementation of electronic versions of these forms so that they are always available to EHR users. Work Schedule: 8AM - 4:30PM, Monday - Friday Telework: Ad-hoc only Virtual: This is not a virtual position. Functional Statement #: 00000 Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized

You must be a U.S. Citizen to apply for this job. Selective Service Registration is required for males born after 12/31/1959. Must be proficient in written and spoken English. Subject to background/security investigation. Selected applicants will be required to complete an online onboarding process. Acceptable form(s) of identification will be required to complete pre-employment requirements (https://www.uscis.gov/i-9-central/form-i-9-acceptable-documents). Effective May 7, 2025, driver's licenses or state-issued identification cards that are not REAL ID compliant cannot be utilized as an acceptable form of identification for employment. Participation in the seasonal influenza vaccination program is a requirement for all Department of Veterans Affairs Health Care Personnel (HCP). Complete all application requirements detailed in the "Required Documents" section of this announcement. As a condition of employment for accepting this position, you will be required to serve a 1 or 2-year trial period during which we will evaluate your fitness and whether your continued employment advances the public interest. In determining if your employment advances the public interest, we may consider: your performance and conduct; the needs and interests of the agency; whether your continued employment would advance organizational goals of the agency or the Government; and whether your continued employment would advance the efficiency of the Federal service. Upon completion of your trial period, your employment will be terminated unless you receive certification, in writing, that your continued employment advances the public interest.