Health Info/coding Specialist

2 weeks ago

Kingston, Canada Kingston Health Sciences Centre Full time

To ensure the completeness, quality and accessibility of accurate health record information by coding, analyzing, assembling and abstracting data from the patients’ records. To conduct audits and provide interpretation of the data in the Med2020 Winrecs abstracting computer system. To code and abstract data from the patients records which will provide support statistical analysis, research and peer review by hospital staff, Ministry of Health and CIHI.

Within this role the employee is accountable for contributing to the delivery of the Kingston Health Sciences Centre strategy. As an employee, one must demonstrate an awareness of and be responsible for actively promoting and supporting patient and family centered engagement and care in all we do.

**PRINCIPLE DUTIES & RESPONSIBILITIES**:

- For Inpatient admissions and discharges or For Ambulatory Care visits to the Emergency Department, Day surgery Suite or Clinics: To accurately assign diagnosis and intervention codes according to the ICD-10-CA, CCI or ICD-O classifications. Follow established coding guidelines from CIHI, WHO, CCO and the Hospital.
- To accurately abstract defined data elements from the patients’ charts into the Med2020 computerized Winrecs abstract program in accordance with CIHI, MOH, OPIS and the hospital’s requirements.
- To prepare, edit and correct the abstract data for accurate and timely submission to CIHI and CCO. To perform quality assurance audits to maintain data integrity. To ensure the timely electronic transfer of the abstract data to CIHI and CCO after completion of the month-end process. To correct any errors and submit corrections electronically.
- To ensure accurate assignment of the Case Mix Groups (CMG) Resource Intensity Weights (RIW) and complexity level to each abstract for use in the assessment of resource utilization. To provide coding expertise to the Decision Support and Utilization analysts. The abstracted data will be extracted for research, statistical analysis, quality assurance audits etc. by hospital administration and medical personnel.
- To thoroughly analyze each patient chart for completeness and accuracy, to identify all reports that require completion or signature according to hospital policies, accreditation standards and other statutory requirements. Enter the deficiencies into the computerized Chart Deficiency program (Med2020 or Oncology).
- To verify the integrity of the documentation, identify all missing reports and results. Inform the Manager(s) if a consistent pattern of missing documents is identified.
- To assist physicians with their chart completion and to re-audit the charts to ensure completion. Update the Chart Deficiency Program. To participate in orientation for the physicians re deficiency completion.
- To maintain an organized consistent flow of charts to make available deficient charts to the physicians in a timely manner. This includes performance of clerical workflow functions (assembling, triage) as required.
- To review the patient record and bring forward to the attention of the Director and/or Risk Management Office any cases that are potentially compensable, misadventures or unusually not compliant with Legislation or Hospital standards, e.g. no consent for a procedure.
- Maintain confidentiality of information handled on a daily basis in accordance with the hospital policy. Ensure that only authorized personnel are allowed access to patient records. Assists the clerical staff upon request to determine the right to access information.
- In the absence of the Manager and Release of Information Coordinator, to action verbal requests for release of patient information or to attend in court pursuant to a subpoena.
- To develop and maintain a professional working liaison with other departments and personnel in the hospital.
- To participate in orientation and training the physicians on case mix groups, RIW’s, complexity levels, disease staging and chart deficiency completion.
- To participate in the orientation /training of new employees or Health Information Management students.
- Participates in the Quality Assurance program set out for the Patient Records and Registration Department as well as supporting other hospital departments’ programs.
- The Employee will adhere to the worker responsibilities as set out in the Occupational Health & Safety Act, hospital safety policies, and dept/unit established procedures at all times. Where possible, take corrective action to address a hazard, otherwise report the unresolved hazard, dangerous circumstance, unsafe situation to self, other co-workers or the community, to their supervisor. Should the employee suffer a workplace injury or illness, he/she will advise their supervisor; actively participate in identifying and resolving the underlying cause(s), and participates in early and safe return to work as per Workplace Safety & Insurance Act.
- Understands and is familiar with all pertinent KGH policies and procedures inclu

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