Health Information Management Professional (TFT 1.0 FTE)

The Health Information Management Professional is responsible for ensuring the delivery of complete and accurate clinical records in full compliance with provincial legislation, Accreditation Canada and standards of practice within an established time frame following the completion of any active episode of care and information management process and liaises directly with clinical staff to facilitate this mandate.

Duties

Quantitative\Qualitative Analysis of Clinical Records for Completeness

• Performs a quantitative/qualitative analysis of the clinical record for completeness, accuracy, validity to ensure information meets hospital accreditation standards, statutory and legal requirements
• Assign lab reports electronically to physicians
• Verification of scanned documents in the electronic medical record system
• Audits scanned documents before destruction Verification of scanned documents in the electronic medical record

Completion of NACRS abstracts and RAI tool

• Resolves/clarifies conflicting, missing or unclear information with physician
• Abstracts and codes Electroconvulsive Therapy visits

Closing Out-Patient Visits

• Periodically print list of open outpatient visits and review charts and direct to appropriate physician to complete closure procedure.

Other duties

• Provide back-up assistance with other Clinical Record duties as needed to cover sick/vacation leave.
• Assist staff with questions related to clinical records
• Training of H.I.M. students from Community College.
• Works in a manner that is in compliance with staff and patient/client safety practices, policies and procedures of the Royal.
• Ensures a work environment that is conducive to the Royal’s Harassment-Free Workplace policy.
• Other duties as required by the Director/Manager of the Service.

Qualifications

• College diploma – Health Information Management (HIM) required.
• Certification with and member in ‘good standing’ with Canadian Health Information Management Association (CHIMA) required.
• Intermediate computer skills – Microsoft Office (Word/Excel).
• Keyboarding skills, speed of 20 words per minute with high accuracy.
• Good organizational skills and interpersonal skills.
• Strong attention to detail.
• Excellent communication skills both verbal and written.
• Excellent attendance.
• Ability to work under pressure.
• Ability to manage heavy workload and meet deadlines.
• Demonstrated experience with ICD 10 coding.
• Knowledge and experience with MediTech an asset.
• English level A- is mandatory in oral expression, oral comprehension, reading and writing. Bilingual (French/English) is considered an asset.