HEALTH INFORMATION ADMINISTRATOR (NACRS)

Posting #: 905415
Union: Non-Union
Site: Toronto General Hospital
Department: UHN Data Analytics
Reports to: Manager
Hours: 15 hours per week

Salary: $25.98 to $32.48 per hour (To commensurate with experience and consistent with UHN compensation policy)
Status: Temporary Part-Time, 12 Months
Posted Date: Dec 23, 2023
Closing Date: Until Filled

The University Health Network, where “above all else the needs of patients come first”, encompasses Toronto General Hospital, Toronto Western Hospital, Princess Margaret Cancer Centre, Toronto Rehabilitation Institute and the Michener Institute of Education. The breadth of research, the complexity of the cases treated, and the magnitude of its educational enterprise has made UHN a national and international resource for patient care, research and education. With a long tradition of ground breaking firsts and a purpose of “Transforming lives and communities through excellence in care, discovery and learning”, the University Health Network (UHN), Canada’s largest research teaching hospital, brings together over 16,000 employees, more than 1,200 physicians, 8,000+ students, and many volunteers. UHN is a caring, creative place where amazing people are amazing the world.

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.

Position Summary

As an integral member of the Coding and Abstracting Department, the Health Information Management (HIM) Professional – NACRS 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 - NACRS 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)

  Duties

  Ambulatory 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) visit for the purpose of coding and abstracting all mandatory health data required to complete a National Ambulatory Care Reporting System (NACRS) 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, 10thedition (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 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) 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 assignment and Ambulatory Case Weight (ACW) calculations. Correct CACS assignment and ACW 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.

              (6) 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.

                (7) 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.

                  (8) 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.

                    (9) Maintains and protects patient confidentiality at all times.

                    (10) Performs cross-functional and/or other duties consistent with the department operational needs, as assigned or required.

                    Qualifications

                    • Successful completion of 2 year Health Information Management community college diploma required
                    • Successful completion of CHIMA (Canadian Health Information Management Association) a recognized HIM program required
                    • Successfully challenged the CHIMA National Certification Examination or hold a valid CHIMA certificate required
                    • Maintains active/inactive CHIMA membership (payment of annual dues) required
                    • One (1) year working experience with ICD-10-CA and CCI classification systems in an acute care institution preferred
                    • Knowledge of current CIHI Coding Standards, NACRS Abstracting Guidelines and Ontario Ministry of Health (MOHLTC) data quality initiatives preferred
                    • Experience working in a Microsoft Windows environment preferred
                    • Knowledge of Comprehensive Ambulatory Classification System (CACS) grouping methodology and Ambulatory Case Weights (ACW) methodology preferred
                    • Knowledge of Day Procedure Grouping (DPG) methodology preferred
                    • Demonstrated ability working with computerized abstracting systems (e.g., Med2020 WinRecs) required
                    • Interest and aptitude in working with computers and specialized software required
                    • Ability to read medical records to determine completeness required
                    • Ability to work under pressure and manage competing priorities required
                    • Ability to work independently and within a team environment required
                    • Thorough understanding of medical terminology, anatomy, physiology, pathology, and diseases processes required
                    • Accuracy and attention to detail required
                    • Good interpersonal skills required
                    • Good problem solving and analytical skills required
                    • Effective verbal and written communication skills required
                    • Manual dexterity and good vision required
                    • Proven ability to attend work regularly required
                    • Active membership with the Canadian Health Information Management Association (CHIMA) preferred
                    • Active membership with the Ontario Health Information Management Association (OHIMA) preferred
                    • All active CHIMA members must participate in mandatory Continuing Professional Education (CPE) program, as defined by the governing regulations, in order to continue to use their professional designation

                      Why join UHN?

                      In addition to working alongside some of the most talented and inspiring healthcare professionals in the world, UHN offers a wide range of benefits, programs and perks. It is the comprehensiveness of these offerings that makes it a differentiating factor, allowing you to find value where it matters most to you, now and throughout your career at UHN.

                      • Competitive offer packages
                      • Government organization and a member of the Healthcare of Ontario Pension Plan (HOOPP https://hoopp.com/)
                      • Close access to Transit and UHN shuttle service
                      • A flexible work environment
                      • Opportunities for development and promotions within a large organization
                      • Additional perks (multiple corporate discounts including: travel, restaurants, parking, phone plans, auto insurance discounts, on-site gyms, etc.)

                        Current UHN employees must have successfully completed their probationary period, have a good employee record along with satisfactory attendance in accordance with UHN's attendance management program, to be eligible for consideration.

                        Vaccines (COVID and others) are a requirement of the job unless you have an exemption on a medical ground pursuant to the Ontario Human Rights Code.

                        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. Applicants need to make their requirements known in advance. Any information received related to an accommodation will be addressed confidentially.

                        University Health Network thanks all applicants, however, only those selected for an interview will be contacted.

                    • About the company

                      The University Health Network (UHN), consisting of Princess Margaret Cancer Centre, Toronto General Hospital, Toronto Western Hospital and Toronto Rehabilitation Institute, is a recognized leader in patient care, research and education.

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