Summary This position is located in the Health Information Management (HIM) Section of the Business Office Service at the Jack C. Montgomery VA Medical Center. Medical Records Administrators (MRAs) in VHA perform or supervise work concerned with the management of a health record program or the provision of services related to medical record administration/health information services. Responsibilities 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/or 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, The Joint Commission (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 complete health 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 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 and 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. Serves as 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. Recommends improvements in health record 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 health record entries and reports findings with subsequent trending of data. Provides management officials with health record review results and trends on an ongoing basis. Monitors and reports delinquent records by number, type of deficiencies and responsible provider. Serves as a resource for patient data on both patient-specific and aggregate databases. Represents Business Office 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, TJC standards, record retrieval processes, health record components, systems, goals, electronic records, etc. Serves as a key member of the Quality Improvement (QI) team, works closely with QI personnel, and is responsible for assuring that the facility is compliant with all TJC standards regarding health information. Responsible for assuring that all patients have a complete, accurate, and timely record of their health care at the facility and must assure that such information is appropriately stored and readily available for the provision of medical services to the patients. Responsible for leading the automation of all health information systems, working closely with Information Technology (IT) and Clinical Informatics - must guide the automation of health record documentation, health record tracking, and physician incomplete record tracking. Must support the information security program and manage much of the patient information database within VistA. Incumbent will work with a variety of hardware and software. Perform other duties as assigned. Work Schedule: Full-time, Monday - Friday, 8:00am - 4:30pm Telework: No Virtual: This is not a virtual position. Functional Statement #: 540930 Requirements Conditions of Employment 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 dentification cards that are not REAL ID compliant cannot be utilized as an acceptable form of identification for employment. Must pass pre-employment physical examination. 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. Qualifications Basic Requirements: Citizenship. Must be a citizen of the United States Education or Experience: (1) 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, (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 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. Certification: Employees at this level must have a HIM Certification. Health Information Management (HIM) Certification. Higher-level health information management certification is limited to certification obtained through AHIMA. To be acceptable for qualifications, the specific certification must represent a comprehensive competency in the occupation. Certification titles may change and certifications that meet the definition of HIM certification may be added/removed by the above certifying body; however, current HIM certifications include Registered Health Information Technician (RHIT) and Registered Health Information Administrator (RHIA). 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). Grade Determinations: In addition to the basic requirements for employment, the following criteria must be met when determining the grade of candidates. Medical Records Administrator (Chief (CHIM)), 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. 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. Reference: For more information on this qualification standard, please visit https://www.va.gov/ohrm/QualificationStandards/. The full performance level of this vacancy is GS-11. This announcement will be hired at GS-13. Physical Requirements: According to VA Directive and handbook 5019, Employee Occupational Health Services. Education Note: Only education or degrees recognized by the U.S. Department of Education from accredited colleges, universities, schools, or institutions may be used to qualify for Federal employment. You can verify your education here: http://ope.ed.gov/accreditation/. If you are using foreign education to meet qualification requirements, you must send a Certificate of Foreign Equivalency with your transcript in order to receive credit for that education. For further information, visit: https://sites.ed.gov/international/recognition-of-foreign-qualifications/. Additional Information Receiving Service Credit or Earning Annual (Vacation) Leave: Federal Employees earn annual leave at a rate (4, 6 or 8 hours per pay period) which is based on the number of years they have served as a Federal employee. Selected applicants may qualify for credit toward annual leave accrual, based on prior work experience or military service experience. This credited service can be used in determining the rate at which they earn annual leave. Such credit must be requested and approved prior to the appointment date and is not guaranteed. During the application process you may have an option to opt-in to make your resume available to hiring managers in the agency who have similar positions. Opting in does not impact your application for this announcement, nor does it guarantee further consideration for additional positions. This job opportunity announcement may be used to fill additional vacancies. This position is in the Excepted Service and does not confer competitive status. VA encourages persons with disabilities to apply. The health-related positions in VA are covered by Title 38, and are not covered by the Schedule A excepted appointment authority. If you are unable to apply online or need an alternate method to submit documents, please reach out to the Agency Contact listed in this Job Opportunity Announcement. Under the Fair Chance to Compete Act, the Department of Veterans Affairs prohibits requesting an applicant's criminal history prior to accepting a tentative job offer. For more information about the Act and the complaint process, visit Human Resources and Administration/Operations, Security, and Preparedness (HRA/OSP) at The Fair Chance Act.