Medical Records Administrator - CHIM Job in Salisbury, NC

Summary

This job is open to

• The public

  U.S. Citizens, Nationals or those who owe allegiance to the U.S.

• Federal employees - Competitive service

  Current federal employees whose agencies follow the U.S. Office of Personnel Management's hiring rules and pay scales.

• Federal employees - Excepted service

  Current federal employees whose agencies have their own hiring rules, pay scales and evaluation criteria.

• Veterans

  Veterans of the U.S. Armed Forces or a spouse, widow, widower or parent of a veteran, who may be eligible for derived preference

Duties

The Medical Records Administrator - Chief CHIM duties includes, but are not limited to the following:

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, 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.

Clinical support role: The incumbent 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. 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 to guide and assist on research projects and is a resource for patient data on both patient-specific and aggregate databases. Represents HAS 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.

Responsible for assuring that all patients have a complete, accurate, and timely record of their health care at the facility. Must assure that such information is appropriately stored and readily available for the provision of medical services to the patients.

As a resource for the medical center, incumbent conducts 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 coordinating health information training for medical school students and residents to achieve conformance with prescribed standards.

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. Resolves informal complaints and grievances.

Work Schedule: Monday - Friday 8am - 4:30pm
Telework: Not Available
Virtual: This is not a virtual position.
Relocation/Recruitment Incentives: Not Authorized
Permanent Change of Station (PCS): Not Authorized

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.
• You may be required to serve a trial period.
• 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.
• Participation in the seasonal influenza vaccination program is a requirement for all Department of Veterans Affairs Health Care Personnel (HCP).

How You Will Be Evaluated

Required Documents

How to Apply

All applicants are encouraged to apply online. To apply for this position, you must complete the full questionnaire and submit the documentation specified in the Required Documents section below. The complete application package must be submitted by 11:59 PM (ET) on 09/15/2025 to receive consideration. To preview the questionnaire click https://apply.usastaffing.gov/ViewQuestionnaire/12791055.

1. To begin, click Apply Online to create a USAJOBS account or log in to your existing account. Follow the prompts to select your USA JOBS resume and/or other supporting documents and complete the occupational questionnaire.
2. Click Submit My Answers to submit your application package.

Next steps

Once your online application is submitted you will receive a confirmation notification by email. After we receive application packages (including all required documents) and the vacancy announcement closes, we will review applications to ensure qualification and eligibility requirements are met. After the review is complete, a referral certificate(s) is issued and applicants will be notified of their status by email. Referred applicants will be notified as such and may be contacted directly by the hiring office for an interview. All referred applicants receive a final notification once a selection decision has been made.

You may check the status of your application at any time by logging into your USA Jobs account and clicking on Applications. Information regarding your application status can be found in the USAJobs Help Center.

NOTE: Participation in the seasonal influenza program is a condition of employment and a requirement for all Department of Veterans Affairs Health Care Personnel (HCP). It is a requirement that all HCP to receive annual seasonal influenza vaccination or obtain an exemption for medical or religious reasons. Wearing a face mask is required when an exemption to the influenza vaccination has been granted. HCP in violation of this directive may face disciplinary action up to and including removal from federal service. HCP are individuals who, during the influenza season, work in VHA locations or who come into contact with VA patients or other HCP as part of their duties. VHA locations include, but are not limited to, VA hospitals and associated clinics, community living centers (CLCs), community-based outpatient clinics (CBOCs), domiciliary units, Vet centers and VA-leased medical facilities. HCP include all VA licensed and unlicensed, clinical and administrative, remote and onsite, paid and without compensation, full- and part-time employees, intermittent employees, fee basis employees, VA contractors, researchers, volunteers and health professions trainees (HPTs) who are expected to perform any or all of their work at these facilities. HPTs may be paid or unpaid and include residents, interns, fellows and students. HCP also includes VHA personnel providing home-based care to Veterans and drivers and other personnel whose duties put them in contact with patients outside VA medical facilities.