Coding and Documentation Specialist
- Job ID
- # Positions
- Health Information Management
- Job Type
- Full Time
- Closed Date
We are a large acute care, community hospital serving Cambridge, North Dumfries and the Region of Waterloo with 280 physicians, 1100 full- and part-time professional health care staff and more than 400 active volunteers. Our vision is to provide exceptional healthcare by exceptional people, with an emphasis on giving patients and their families an exceptional experience when they visit our hospital. With help from our Foundation partners and our supportive community, we purchase over $4 million of medical equipment each and every year to help ensure you will work with the best tools possible when caring for your patients. In collaboration with universities and colleges, we are also a teaching and placement site for medical, nursing and allied health programs. To learn more about Cambridge Memorial Hospital (CMH), please visit our website at www.cmh.org.
You will join CMH as we embrace a new era of care, expanded services and innovation. Construction is underway of a modern 5-storey tower and total renovation of all existing inpatient care and clinical support areas. Upon completion, our new hospital will contain:
- Patient care areas that are doubling in size, including larger surgical suites to accommodate advanced minimally invasive surgical equipment and an Emergency Department with dedicated treatment areas for mental health and different surgical subspecialties
- A patient-centred building design that promotes healing and intuitive wayfinding, while maximizing natural lighting and sight lines to the natural beauty of the Grand River
- An increase in beds from 143 to 197 to accommodate expanded services like Surgery, Mental Health and Intensive Care. About 80% of inpatient rooms will be single occupancy to meet the latest infection control and building code standards for hospitals
The Coding and Documentation Specialist must be experienced and knowledgeable of all types of acute care coding, coding standards and demonstrate a good understanding of the HIG Grouper and the various factors that can impact HIG weights. This role is accountable to work with physicians and coders to ensure that documentation reflects the complexity of illness. This includes;
- Review of clinical documentation,
- Regular coding audits,
- Provide orientation to new physicians focusing on expectations and common documentation issues/challenges within their specialty,
- Regularly attend physician specialty meetings to highlight documentation issues and address with individual physicians.
- Arrange regular coding meetings, and coder education,
- Review & implement annual CIHI changes and requirements for QBP funding,
- Act as a resource for complex charts,
- Review queries to physicians and Project 100 and ensure all corrections are submitted prior to the end of the reporting period
- You will also maintain strict confidentiality of all patient information in accordance with PHIPA.
This is a full time position to work days Monday to Friday. Posted hours do not constitute a guarantee that shifts will not be subject to change.
The physical demands of the role may include, but are not limited to prolonged sitting, standing, walking, bending, lifting, pushing and pulling. This position contributes to ensuring there is a safe environment for patients, staff and visitors.
Skills and Qualifications:
- Graduate of an accredited Health Information Management program required
- Certification with the Canadian Health Information Management Association (CHIMA) in good standing is required
- Minimum 5 years of current experience for coding and abstracting
- A degree in nursing or other clinical discipline is preferred
- Experience providing group education
- Proficiency with electronic abstracting and computer applications (Word and Excel). Experience with Meditech and 3M would be an asset
- Must have excellent skills for case analysis and interpretation for the ICD 10 coding classification.
- Must have an understanding and knowledge of grouping and weighting methodologies (ie. CMG, RIW, Complexity, CACS and ACW)
- Ability to apply quality practices and standards to coding and abstracting.
- Ability to work independently, prioritize workload, meet deadlines and work effectively under pressure and show good judgment
- Familiar with relevant legislative requirements for release of personal information (Personal Health Information Protection Act, Mental Health Act, Public Hospital Act, Freedom of Information Act, Coroners Act etc.)
- Excellent customer service, interpersonal and communication skills are required
- Excellent organization and time management skills
- Demonstrated ability to attend work on a regular basis is required
Cambridge Memorial Hospital is committed to providing and fostering a respectful workplace. All reasonable accommodation will be made to support participation in the recruitment process. Where needed, accommodations for disabilities will be provided, on request, to support participation in all aspects of the recruitment process.