Job Description

Salary Range: $45.62 - $54.30

Position Summary

Coding and Documentation Specialist/HIM Supervisor must be experienced and knowledgeable of all types of acute care coding and coding standards. In addition, the Coding and Documentation Specialist/HIM Supervisor must have good knowledge of HBAM funding methodology. The Coding and Documentation Specialist/HIM Supervisor will facilitate improvement in the overall quality, completeness and accuracy of medical documentation to ensure coded data reflect the care provided to patients. 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.

The Coding and Documentation Specialist/HIM Supervisor will regularly attend physician specialty meetings to highlight documentation issues and address with individual physicians. Arrange regular coding meetings, educate coders, review & implement annual CIHI changes and requirements for QBP funding, act as a resource for complex charts, review and monitor queries to physicians, Project 100 and ensure all corrections are submitted prior to the end of the reporting period. Maintain strict confidentiality of all patient information in accordance with PHIPA.

This is a full time position to work days Monday to Friday.

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.

Posted hours do not constitute a guarantee that shifts will not be subject to change.

Key Responsibilities and Accountabilities:

• Foster relationships between the various disciplines
• Liaison between clinical and business side of healthcare
• Facilitate extensive day to day interactions with the coding team, decision support and physician groups
• Establish process for flagging charts for review and facilitate chart review process including:
  • Evaluation of opportunities for improvement that impact HIG weight, QBPs, HSMR, Benchmark LOS
  • Query to physicians to gain clarity on documentation to ensure accurate code assignment
  • Summary of findings / results
  • Identify trends and education opportunities
  • Present findings
• Enable timely, accurate and complete documentation of clinical information used for measuring and reporting physician and facility outcomes and to ensure top quality data for decision making

Skills and Qualifications:

• Graduate of an accredited Health Information Management program required
• Certification with the Canadian Health Information Management Association (CHIMA) in good standing
• Minimum 5 years of current experience coding NACRS and DAD and abstracting
• Supervisory and leadership experience
• 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 with the expectation for implementing ICD 11 coding
• Must have an understanding and knowledge of grouping and weighting methodologies (i.e. CMG, HIG, RIW, Complexity, CACS and ACW)
• Must have knowledge of hospital funding methodologies HBAM, QBP, PCOP
• 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

As part of our commitment to the health and safety of our patients, staff and community from COVID-19, subject to any accommodation required by applicable human rights legislation, Cambridge Memorial Hospital requires that all staff have received all required doses of a COVID-19 vaccine approved by Health Canada.

The successful external applicant is required to provide the applicable criminal record check, as requested by Human Resources, in accordance with federal and provincial legislation. Valid criminal record checks are in original format and dated with two months from date of conditional offer from CMH.

We thank all those who apply, however only those selected for an interview will be contacted.

Cambridge Memorial Hospital (CMH) proudly integrates AI-based technologies into its applicant screening process to enhance recruitment. These tools are designed to reduce bias and uphold fair hiring practices based on skills, education, and experience. CMH's AI serves to assist, not replace, human decision-making, with results audited to ensure quality and equity. This initiative reinforces the hospital's commitment to Equity, Diversity, and Inclusion, ensuring the best talent is selected while adhering to its core values.

Union

Non-Union