Health Information Clerk - Health Records

Salary: The salary range for this position is CAD $35.27/Hr. - CAD $44.05/Hr. Summary: Within the context of a client and family centred model of care and, in accordance with the Mission, Vision and Values, and strategic directions of Providence Health Care, the person promotes a safe, respectful, and civil working environment for patients, residents, families, visitors and staff. Reporting to the Coordinator, Coding, performs coding and abstracting of health records according to established guidelines utilizing computerized systems and in accordance to national, provincial and regional requirements. Processes corrections for abstracts for data quality, maintains the computerized abstracting system, and participates in continuous quality improvement activities. Provides data related to specific projects and/or assignments as requested, assists in the presentation of statistical information and participates on organizational committees by providing advice regarding codes, classification, mapping and data collection. Education, Training, and Experience Graduate of an approved Health Information Management Program. Canadian College of Health Information Management (CHIM) Certified and active membership with the Canadian Health Information Management Association (CHIMA). Demonstrated ability to code/abstract in the current CIHI and BC Ministry of Health standard classification system.

Demonstrated knowledge of computerized coding and abstracting systems.

Demonstrated ability to communicate effectively, both verbally and in writing.

Demonstrated ability to operate related equipment including the ability to perform rudimentary functions in spreadsheet, database, and word processing software and demonstrated ability to use a keyboard and mouse.

Performs coding and abstracting duties such as CIHI Discharge Abstract Database, the Trauma Registry, the Canadian Neonatal Network, the BC Perinatal Database, National Ambulatory Care Reporting System and other Coding databases according to established guidelines and BC Ministry of Health requirements to provide a current and accurate hospital database for statistics and/or research purposes by methods such as utilizing computerized systems. Ensures data quality of assigned work by performing duties such as reviewing the data capture for accuracy and completeness. Assesses quality of documentation within the patient record to ensure accurate coding and abstracting. Participates in the development of data definitions, data modeling and design activities to support appropriate information availability in the health record. Completes period end function and system updates/corrections by performing duties such as reviewing patient files to ensure every patient discharged has been coded and abstracted appropriately, checking the computerized Admission, Discharge and Transfer System against the computerized abstracting system to ensure that all discharge functions have been captured and following-up on discrepancies. Participates in continuous quality improvement activities and service excellence by performing duties such as making recommendations to the Coding Coordinator and participating in implementing changes as required. Provides data related to specific projects as requested such as generic screening and quality indicators for research, clinical and administrative assignments by performing duties such as receiving requests, collecting and analyzing data and statistical information and forwarding to designated personnel as required. Assists in the presentation of statistical information to parties such as other hospital departments, committees and outside agencies by performing duties such as retrieving data and statistical information, analyzing data and conducting presentations as required. Supports internal/external Analysts acting as a coding subject matter expert by performing duties such as sharing knowledge, providing input on coding related matters and responding to questions. Assists in clinical mapping and various activities related to structured data. Provides input into policies and procedures by participating in the examination of the existing policies to determine if updating is required, reviewing work processes to identify problems and inefficiencies for discussion, evaluating technical literature/material to identify new or revised procedures/equipment to improve operations, and making recommendations into the development of, or changes to, selected policies, procedures or protocols. Prepares new or revised forms for review and consideration by the Coding Coordinator. Participates on organizational committees by performing duties such as acting as a liaison and resource person for Health Information Management to other departments, providing advice to departments regarding codes, classification and data collection and making recommendations as required. Maintains an acceptable level of expertise in health information management through the review of literature, contact with peer professionals and attendance at educational sessions. Acts as a data resource person for the clinical programs by demonstrating procedures to staff and providing information to system users. Provides orientation and supervision as required to students by demonstrating and providing opportunity to observe health record administration processes and procedures, instructing, and providing feedback. Assists with orientation new staff members to processes and procedures and answering related questions. Collects and reports workload data.