Coding Analyst II, Discharge Abstract Database (DAD)

Job description

Company Description UHN is Canada’s #1 hospital and the world’s #1 publicly funded hospital. With 10 sites and more than 44,000 TeamUHN members, UHN consists of Toronto General Hospital, Toronto Western Hospital, Princess Margaret Cancer Centre, Toronto Rehabilitation Institute, The Michener Institute of Education and West Park Healthcare Centre. As Canada's top research hospital, the scope of biomedical research and complexity of cases at UHN have made it a national and international source for discovery, education and patient care. UHN has the largest hospital-based research program in Canada, with major research in neurosciences, cardiology, transplantation, oncology, surgical innovation, infectious diseases, genomic medicine and rehabilitation medicine. UHN is a research hospital affiliated with the University of Toronto. UHN’s vision is to build A Healthier World and it’s only because of the talented and dedicated people who work here that we are continually bringing that vision closer to reality. www.uhn.ca Job Description Union: Non-Union Number of Vacancies: 1 New or Replacement Position: Replacement Site: Toronto General Hospital Department: Coding and Abstracting Reports to: Manager Salary Range: $68,932 - $103,409 per annum Hours: 37.5 hours per week Status: Permanent Full-Time Closing Date: June 18, 2026 Position Summary As an integral member of the Coding and Abstracting Department, the Health Information Management (HIM) Professional – DAD 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. Duties Inpatient 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 DAD inpatient 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. Diagnosis: Interprets and determines all relevant conditions described by the physician and/or other health providers associated with the ambulatory visit being reviewed. Utilizing the International Statistical Classification of Diseases and Related Health Problems, 10th edition (ICD-10-CA) 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. 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. 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. 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. 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. 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. Maintains and protects patient confidentiality at all times. 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 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 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 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 Active membership with the Canadian Health Information Management Association (CHIMA) preferred Active membership with the Ontario Health Information Management Association (OHIMA) preferred Additional Information 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. All applications must be submitted before the posting close date. UHN uses email to communicate with selected candidates. Please ensure you check your email regularly. Please be advised that a Criminal Record Check may be required of the successful candidate. Should it be determined that any information provided by a candidate be misleading, inaccurate or incorrect, UHN reserves the right to discontinue with the consideration of their application. UHN is an equal opportunity employer committed to an inclusive recruitment process and workplace. Requests for accommodation can be made at any stage of the recruitment process. Applicants need to make their requirements known. We thank all applicants for their interest, however, only those selected for further consideration will be contacted.