Medical Records Administrator

Duties to include but not limited to the following:

• Oversees all facets of health records management for the facility ensuring maintenance of completed accurate timely clinically-pertinent and readily-accessible patient health records.
• Exercises independent judgment in carrying out duties and responsibilities and has complete authority to plan design and direct the HIM program; recommendations and/or technical decisions made by employee are not reviewed.
• Provides administrative management of health records: 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.
• Creates and monitors systems to ensure accurate timely and complete health records in accordance with VHA policy and The Joint Commission health information protocols.
• Ensures 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.
• 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.
• 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.
• Key advisor to the Chief of Staff Executive Management and clinicians; 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.
• Conducts training programs in health information management medical terminology health record documentation and medico-legal matters. Incumbent is responsible for establishing formal affiliation with university programs in health information and precepting students from such programs.
• 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.
• Responds to the needs of customers; communicates and treats customers in a courteous tactful and respectful manner.

Work Schedule: Monday - Friday 7:30am - 4:00pm
Telework: Ad-Hoc
Virtual: This is not a virtual position.
Functional Statement #62507F
Relocation/Recruitment Incentives: Authorized
Permanent Change of Station (PCS):Not Authorized

• You must be a U.S. Citizen to apply for this job.
• To be considered for this position you must complete all required steps in the process. In addition to the application and questionnaire this position requires an online assessment. The online assessment measures critical general competencies required to perform the 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 ( Effective May 7 2025 drivers 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 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.

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: Proficient in spoken and written English as required by 38 U.S.C. 7402(d).
• Experience and Education:
  • 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 bachelors 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.

Grandfathering Provision: May qualify based on being covered by the Grandfathering Provision as described in the VA Qualification Standard for this occupation (only applicable to current VHA employees who are in this occupation and meet the criteria).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:(1) 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.(2) 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.(3) 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.(4) 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.

Grade Determinations:GS-13

Experience: One year of creditable experience equivalent to the next lower grade level (GS-12) that demonstrates the KSAs described at that level
GS-12 Demonstrated Knowledge Skills and Abilities:

• Ability to determine and evaluate compliance with legal ethical and regulatory guidelines and accrediting bodies as they apply to health information management.
• Skill in evaluating developing and implementing new policies procedures and programs.
• Ability to provide program oversight including advisory and technical expertise on a range of health information management practices and guidelines to staff at various levels.
• Ability to develop and conduct training on health information management programs policies procedures and performance improvement activities.
• Ability to effectively procure and manage HIM resources (i.e. space staffing education budget etc.)
• Ability to provide the full range of supervisory duties to include assignment of work; completing performance evaluations; selection of staff; and recommendation of awards advancements and disciplinary actions.
• Customer service skills necessary to effectively communicate (written and verbal) and interact with all levels of hospital personnel physicians patients and outside agencies.
• Ability to deal effectively with sensitive and/or complex situations.

Certification: Must have a HIM Certification or Coding Certification through AHIMA or AAPC or Health Data Analyst Certification through AHIMA .

GS-13 Demonstrated Knowledge Skills and Abilities:

• Ability to determine and evaluate compliance with legal ethical and regulatory guidelines and accrediting bodies as they apply to health information management.
• Ability to provide sound technical guidance to staff at various levels about major program legal or procedural changes related to health information management.
• Skill in revising facility policies and procedures to improve health information management services and to evaluate modify and/or adapt new methods to meet regulatory requirements.
• Skill in analyzing complex data interpreting and trending results for effective management of the HIM program.
• Skill in management/administration which includes program planning coordination interpretation supervision consultation negotiation problem solving and monitoring of HIM processes.
• Ability to delegate authority evaluate and oversee people and programs accomplish program goals and adapt to changing priorities.

Professional Experience:
Extensive experience in health information management typically 5-10 years with a history of progressively responsible roles .Prior experience in a leadership or supervisory capacity within a HIM department. Experience in a healthcare setting particularly within the Veterans Health Administration (VHA) or other federal healthcare systems can be a strong advantage.

Technical Skills:
Proficiency with electronic health record systems (such as VistA/CPRS) and Health Information Technology (HIT).Strong knowledge of medical coding compliance and regulatory requirements related to health information (e.g. HIPAA ICD-10 CPT etc.).Familiarity with data analytics and performance improvement methodologies.

Leadership and Management Abilities:
Demonstrated ability to lead and manage staff including recruitment training and professional development. Strong project management skills and the ability to navigate complex organizational structures and processes. Ability to develop and implement strategic plans for health information management services.

Interpersonal and Communication Skills:
Excellent verbal and written communication skills with the ability to effectively collaborate with clinicians administrators and external stakeholders. Strong problem-solving skills and the capacity to make informed decisions under pressure.

Compliance and Quality Assurance:
In-depth knowledge of legal and ethical requirements for health information management. Experience with accreditation processes (e.g. The Joint Commission) and quality assurance initiatives in healthcare.

Reference: For more information on this qualification standard please visit full performance level of this vacancy is non-supervisory GS-11 grade level. The actual grade at which an applicant may be selected for this vacancy is GS-13.

Physical Requirements: The work is basically sedentary. Some walking standing bending and carrying items such as books papers boxes laptop and files are also required.