Position #907119
Position: Health Information Administrator – TFT
Department: Coding and Abstracting
Location: Toronto General Hospital
Status: Temporary Full-time (12 months)
Salary N003: $24.85 – $31.07 per hour(based on experience and qualifications)

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University Health Network (UHN) is Canada’s largest academic health sciences center and is affiliated with the University of Toronto. Building on the strengths and successes of our four remarkable hospitals and academic institute; Toronto General Hospital, Toronto Western Hospital, Princess Margaret Hospital, Toronto Rehabilitation Institute, and Michener Institute. UHN brings together new tools, technologies and talent to make us an international leader in healthcare and the ideal place to build your health technology career. For more information on UHN, visit www.uhn.ca.

UHN Digital delivers information management and technology services for the entire organization and is responsible for assisting UHN staff and students in transforming lives and communities.

I. JOB SUMMARY

As an integral member of the Coding and Abstracting Department, the Health Information Management (HIM) Professional – HIM Coder, utilizes his or her technical, analytical and decision-making skills to make appropriate interpretations of ambulatory clinical documentation, drawing upon his or her knowledge of medical and surgical terminology, anatomy, pathology, physiology, pharmacology, and the national and provincial coding standards.

The HIM professional communicates with physicians, residents, nurses, nurse practitioners, nurse managers, business managers, performance measurement analysts, and data quality analysts to exchange information and serve as a resource for coding-related issues.

The HIM Professional – produces information that has strategic importance to the following initiatives:

Calculation of hospital funding

Hospital Accountability Agreement signed by the Hospital Board with the Local Health Integration Network (LHIN)

Strategic planning, clinical utilization management, and performance measurement/monitoring

Patient Satisfaction Survey (Emergency and Ambulatory Oncology)

Patient Safety and Quality of Care (e.g., AMI monitoring for Safer Healthcare Now)

II. DUTIES AND RESPONSIBILITIES

1. Coding

The HIM professional draws upon his or her knowledge of anatomy, pathology, physiology, medical and surgical terminology, pharmacology, and national and provincial coding standards and conventions to make appropriate interpretations of the patient experience as described in relevant dictated and/or written clinical documentation associated with an ambulatory (emergency and day surgery) and/or acute visit for the purpose of coding and abstracting all mandatory health data required to complete an abstract as per the Canadian Institute for Health Information (CIHI) guidelines, Ontario Ministry of Health (MOHLTC) directives and University of Health Network (UHN) strategic initiatives. Abstracted information is entered through an electronic abstracting system.

(1) Diagnosis

- Interprets and determines all relevant conditions described by the physician and/or other health providers associated with the ambulatory visit being reviewed.
- Evaluates conditions to determine impact on resource use and appropriately assigned significance using diagnosis-typing conventions.
- Diagnose code selection using the International Statistical Classification of Diseases and Related Health Problems, 10th edition (ICD-10-CA) classification system. Utilization of an electronic codebook to search for appropriate codes taking into account all inclusion and exclusion criteria.
- Sequences codes appropriately in order to assign the case in the suitable Case Mixed Group and/or Comprehensive Ambulatory Classification System (CACS) grouping. This determines the resource intensity weight (RIW) value of the case that reflects the estimated cost of managing the visit relative to the national standard or average.
- Weighted cases are reported in the Ontario Ministry of Health and Long-term Care (MOHLTC) Hospital Accountability Agreements and impacts hospital funding.

(2) Intervention

Interprets the operative report and/or other procedure notes to determine all relevant interventions performed on the patient during their hospital stay.
Uses the Canadian Classification of Health Interventions (CCI) classification system to select appropriate intervention codes.
Follows the CIHI Coding Standard for coding all interventions that affect Comprehensive Ambulatory Classification System (CACS) and Case Mixed Grouping (CMG) assignment. Appropriately abstracts and sequences procedures identified as flagged interventions, and any interventions specified as mandatory in other chapters within the Standards, taking into account all notes, inclusion and exclusion criteria.
Identifies the principal procedure, which is defined as the most resource intensive intervention performed on the patient. Sequences intervention codes correctly to ensure its impact on CACS/CMG assignment and Ambulatory Case Weight (ACW) calculations. Correct CMG/CACS assignment and RIW calculation will translate into appropriate funding for the hospital.
When applicable, codes and abstracts appropriate intervention attributes such as status (eg. primary or revision), location (eg. right, left, bilateral) and extent (eg. number of bypassed coronary arteries).

(3) Providers

Identifies all providers, which includes attending physician(s), consultant(s), and allied health professional(s), associated with the patient visit. Selection of most responsible physician impacts strategic planning and program reviews.

(4) Registration (Admission and Discharge Information)

Ensures that registration data is consistent with clinical documentation. Admission and discharge information, such as disposition type (admit as an inpatient versus discharged home) has a direct impact on RIW calculation.

(5) MIS Functional Center

Code and abstracts information on all visits to other MIS functional centers during the patient’s hospital visit. MIS functional center information is used for program planning and strategic forecasting.(6) Other pertinent information
Verifies and collects other relevant health data such as responsibility of payment, blood transfusion data, and other facility-defined data elements such as site. Responsibility of payment identifies Out-of-Province and WSIB cases. Collection of this information facilitates billing for these special cases.

2. Performs quality management responsibilities.

Performs data quality review on individual patient records and evaluates clinical information from multiple source systems to ensure accuracy, consistency, and completeness of information in the inpatient abstract prior to CIHI submission.
Communicates with physicians and/or Acute Care Nurse Practitioners (ACNP) whenever there are discrepancies or vague descriptions stated in clinical documentation.
Interacts with Data Quality analyst(s) and/or Performance Measurement Analyst(s) to discuss data quality issues and provide input on how to improve reporting and flagging of cases.
Performs data reconciliation on areas (cases) that are important to hospital funding at the close of each month. Examples include, but are not limited to, the following: Chemotherapy, Radiotherapy and Brachytherapy, Cataract & Surgical Oncology.

3. Performs case studies and chart audits.

- Engages in an interactive and iterative process to independently review a selected health record and chooses appropriate diagnosis and intervention code(s) based on understanding of the national (CIHI) and provincial (Ontario MOHLTC) coding standards.
- Reviews collated results for consistency and variances are discussed with manager
- Participates in Continuous Quality Improvement (CQI) initiatives at UHN, LHIN and provincial level.

4. Maintains professional expertise and credentials.

HIM professionals are required 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. Required to attend CIHI Coding updates as well as Ontario Ministry of Health Data Blitz sessions.

5. Maintains and protects patient confidentiality at all times.

6. Performs cross-functional and/or other duties consistent with the job classification, as assigned or required.

Posting Dates: October 11, 2022 – October 25, 2022

Job #: 907119

For current University Health Network employees: only those who have successfully completed their probationary period, have a good employee record along with satisfactory attendance in accordance with UHN’s attendance management program, and possess all the required experience and qualifications should apply.

UHN Digital thanks all applicants, however, only those selected for an interview will be contacted.

UHN is a respectful, caring, and inclusive workplace. We are committed to championing accessibility, diversity and equal opportunity. Requests for accommodation can be made at any stage of the recruitment process providing the applicant has met the Bona-fide for the open position. Applicants need to make their requirements known when contacted. For more information about UHN, do visit www.uhn.ca