Claims Information Specialist

The Claim Information Specialist draws upon their knowledge of data science and health information management theory to make appropriate interpretations of the ill or injured worker’s claim information as described in relevant dictated and/or written documentation for the purpose of coding and abstracting all mandatory claim data required to:
Complete a claim abstract in compliance with NWISP (National Work Injury Statistics Program) standards and guidelines; Support internal reporting and other strategic organizational initiatives, and; Support Ontario Ministry of Labor (MOL) information requirements.

**Major Duties and Responsibilities**:
1. Coding and Abstracting

Diagnosis Coding
- Interprets and determines all relevant conditions (nature of injury) and affected part(s) of body described by the ill or injured worker, employer, health providers, and/or case managers associated with the claim being reviewed
- Evaluates conditions to determine severity and appropriately assign significance using diagnosis-typing conventions
- Diagnosis code selection using approved coding classification system (eg. CSA-Z795, ICD9/ICD10)
- Utilization of an electronic codebook to search for appropriate codes taking into account all inclusion and exclusion criteria
- Sequences codes appropriately to facilitate data submission and reporting
- Assigns appropriate diagnosis categories on disease claims
- Collect additional diagnosis information such as pre-existing conditions, co-morbidities, late effects, sequela and complications

Injury/Disease Information Coding
- Interprets relevant source documents to determine the “event” which describes the manner in which the injury or disease was produced or inflicted by the identified “source” of injury or disease
- Interprets relevant source documents to determine the “source” which identifies the object, substance, exposure or bodily motion that directly produced or inflicted the injury or disease identified under the nature of injury or disease
- Utilization of an electronic codebook to search for appropriate codes taking into account all inclusion and exclusion criteria
- Identifies correct accident location (standardized geographic codes) and accident place

Worker Information Coding
- Identifies primary and/or secondary occupation associated with the claim using approved occupational classification system (NOC and/or SOC). Selection of appropriate occupation impacts strategic planning and program reviews
- Collects information on ill or injured worker’s years of experience, work start hours and work end hours

Fatality Coding
- Identifies and collects relevant fatality-related information such as cause of death and external cause (E-code)

Exposure Information Coding
- Identifies and determines appropriate primary and secondary exposures described in the source documents
- Collects exposure years

Other pertinent information
- Verifies and collects other relevant claim information such as cancer morphology, smoking status, smoking amount, and project ID

2. Performs data quality management responsibilities
- Performs data quality review on individual claim records and evaluates claim information from multiple sources to ensure accuracy, consistency, and completeness of information
- Communicates with appropriate business areas whenever there are discrepancies and/or vague descriptions stated in the claim documentation
- Interacts with Data Quality Analyst(s) and/or Senior Business Analyst(s) to discuss data quality issues and provide input on how to improve reporting and flagging of cases
- Performs data reconciliation on cases that are important to reporting at the close of each month. Examples include, but are not limited to, the following: Traumatic Mental Stress, Cancers, High Impact Claims, and Fatality Claims
- Participates in data quality exercises and coding discrepancy identification and resolution
- Participate in the development and implementation of departmental policies to ensure data is gathered and tracked efficiently

3. Performs case studies and chart audits
- Engages in an interactive and iterative process to independently review a selected claim record and chooses appropriate diagnosis and accident information codes based on understanding of national coding standards
- Participates in Continuous Quality Improvement (CQI) at provincial and national level

4. Maintains professional expertise and credentials
- HIM professionals are required by CHIMA to acquire a minimum of 36 continuing professional education (CPE) credits in a period of three years to maintain their credentials and professional standing
- CPE credits are acquired through taking HIM-related courses, attending seminars, conferences, workshops, and completing learning modules

5. Maintains and protects worker confidentiality at all times.

6. Client engagement
- Educate/support staff members from different business areas in accessing coding information in ACES
- Provide coding inf