POSITION DESCRIPTION

Transcription

1 POSITION DESCRIPTION Position Details: Title: Clinical Coding Auditor Department: Information Management Service Reports to: Level 4, Clinical Coding Manager Location: Auckland City Hospital PRIMARY FUNCTION: To manage, co-ordinate and undertake a continuous audit program for clinical coders within the ADHB. To provide feedback/education to the clinical coding team and have input into the design, development and implementation of training and education programs for experienced and trainee coders. To assist in the provision of an efficient and effective clinical coding service within the Organisation. Promote the role of the clinical coding department in a positive manner, with both internal and external stakeholders. To have a proactive and positive approach to working with consultants and clinicians to ensure that sufficiently coded information is clearly provided in clinical records to enable high levels of data quality. To provide advice, exchange information, give presentations, negotiate and consult on a wide range of coding issues. The position will be required to produce reports and interrogate coded data. It is expected that this role works closely and collaboratively with the Clinical Coding Manager and Training and Quality Co-ordinator and will provide cover for key roles as appropriate and agreed with the Clinical Coding Manager. KEY ACCOUNTABILITIES Key Result Area Expected Outcomes/Performance Indicators Coding Auditing To contribute to the development of a comprehensive clinical coding audit programme. To undertake coding audits as per the schedule To provide feedback to individual coders, and produce audit reports and recommendations to the clinical coding manager To identify coding trends and issues pertinent to clinical coding audit, to inform coding policy and procedures and agree relevant action with the clinical coding manager. To identify where a financial impact is likely to result from an audit to inform future policy and maximise income potential. Identify training needs through the audit programme of work and liaise with the clinical coding training and quality coordinator and clinical coding manager to provide the necessary training identified Professional presentations of information to coders, managers and clinicians to focus on practices that require review or for educational purposes. To critically examine clinical information and prepare reports on findings for manager To identify ad-hoc audit work as required To have input into the development and implementation of policies/procedures to support the clinical coding audit function Have input into the development of the Clinical Coding Quality & Audit Plan Concerns arising from audit results are discussed immediately with the

2 Coding Manager To interact with clinical staff to obtain clarification of conflicting, ambiguous, or non-specific documentation Work with the clinical coding training & quality coordinator to implement action plans from audits, validation exercises and other related quality activities and requirements Represent ADHB in external clinical coding audit forums and meetings Clinical Coding To provide a mentoring role to clinical coders, communicating complex rules and supporting development of skills To provide relevant information needed for research, audit or other purposes to support decision making by clinicians and managers Assist clinical coders with complex queries To ensure that own levels of understanding and compliance with local policies and National Coding standards are maintained at the highest levels To undertake general coding as and when required. To participate in internal or external training courses as and when required To keep accredited coding status current Negotiate and agree changes to working practices within Specialties in order to obtain higher standards of coding accuracy. Coding Operations Liaise and work in conjunction with the Clinical Coding Manager to ensure the smooth running of the department Any other duties that may become necessary in relation to the position Adhere to ADHB confidentiality policy Relationship Management Develop and maintain effective working relationships with key stakeholders to support the delivery of clinical coding services and ensure an integrated approach to delivery of services MATTERS WHICH MUST BE REFERRED TO THE CLINICAL CODING MANAGER significant financial issues significant quality or safety issues any emerging factors that could prevent achievement of the service/s objectives at year end any matter that may affect the reputation of the service/s or Auckland District Health Board Authorities: None Direct Reports (if applicable): Nil Budget Accountability (if applicable): Nil Relationships: External Internal Committees/Groups Other DHB s Clinical Coding Departments 3M healthalliance staff Ministry of Health Chief Intelligence & Informatics Director IM Operations Scan Centre staff Clinical Coding staff Clinical Records team Data Quality team Clinical staff Service Operations managers Funding & Planning team Administration staff Other ADHB Team Leaders ChartView Support Team meetings Health & Safety Other relevant committees NZ Coding Authority

3 PERSON SPECIFICATION Education & Essential Desired Qualifications Professional Accredited clinical coder qualification Health Information management qualification Clinical coding audit qualification Work Experience 5 years clinical coding experience, preferably in a tertiary hospital, using ICD-10-AM, and a thorough understanding of the NZ Coding Standards Clinical coding of all specialties Demonstrated experience in conducting quality improvement activities and training in relation to ICD-10-AM coded data and knowledge of auditing concepts and principles. Detailed knowledge of clinical coding systems, procedures, and documentation requirements. Supervisory and/or mentoring experience Evidence of report writing skills Presentation skills A sound understanding of casemix-based funding Sound understanding of professional ethics Intermediate computer skills MS Office suite Demonstrated knowledge of NZ Health Sector Advanced computer skills and experience using Microsoft Office, and a variety of clinical and nonclinical IT systems, including the 3M Grouper Personal Characteristics Methodical, logical and calm Strong analytical, numeracy, planning and implementation skills A team player with the ability to motivate and coach people Ability to think through issues and identify solutions. Generates trust and totally discreet, able to work in a collaborative and supportive partnership. Someone who will be respected as a peer who has the wisdom to be able to provide guidance and counsel when required Analytical and organised and an ability to interpret complex information and to use own judgement in finalising reports Ability to influence and support change Strong interpersonal and communication skills Enthusiastic personality and a good sense of humour Resourceful and resilient; able to cope under pressure. Ability to resolve conflict The ability to challenge and question the status quo (i.e. processes and systems) and facilitate the development of innovative and workable performance improvements Sets the highest ethical and professional standards and leads by example in all interactions. Outcome/solution focussed Ability to work independently or as part of a team Experience of presenting highly complex information to audiences with varied levels of understanding Able to organise and prioritise own workload under pressure and meet deadlines To be able to interpret various clinical coding reports Ability to identify various data quality errors Ability to apply different training delivery techniques to suit individual needs To be able to develop structured clinical coding training

4 Critical Competencies Competency Description 1. Quality Orientation Understanding of quality management principles and practices. Identifying conditions that might affect the quality of a product or service. Constantly striving to do things better whilst focusing on the quality of service, delivery and job activity. 2. Attention to detail Completes tasks in accordance with departmental procedures and work practices. Able to maintain accurate departmental statistics. 3. Work Standards and Self Management Setting high goals or standards of performance for self and others; being dissatisfied with average performance; imposing standards of excellence on self rather than having standards imposed by others. 4. Planning & Organising Establishing a course of action for self or others to accomplish work goals, appointments and activities; planning proper assignments of personnel and appropriate allocation of resources. 5. Oral Communication Expressing ideas effectively (including non-verbal communication) in individual and group situations; adjusting language and terminology to the characteristics and needs of the audience. 6. Collaboration Working effectively with others in the organisation outside the line of formal authority (such as peers in others departments or senior management) to accomplish organisational goals and to identify and resolve problems. 7. Individual Leadership (Empowerment) Creating a sense of ownership of job or tasks by providing clear expectations, control of resources, responsibility and coaching; offering assistance without removing responsibility. 8. Influence Using appropriate interpersonal styles and methods to inspire and guide individuals toward goal achievement; modifying behaviour to accommodate tasks, situations, and individuals involved. 9. Innovation Generating creative solutions to work situations; trying different and novel ways to deal with problems and opportunities. 10. Ability to Learn Accepts new ideas; assimilates new information; applies that which is being learned. 11. Team Work (Cooperation) Active participation in, and facilitation of, team effectiveness; taking actions that demonstrate consideration for the feelings and needs of others; being aware of one's behaviour on others. 12. Value Diversity Understand significance of Treaty of Waitangi Display cultural sensitivity Appreciate insights and ideas of all individuals and work effectively with these differences.

5 WORKING FOR ADHB EXPECTATIONS OF EMPLOYEES CITIZENSHIP All employees are expected to contribute to the innovation and improvement of Auckland District Health Board as an organisation. This means: Using resources responsibly Models ADHB values in all interactions Maintaining standards of ethical behaviour and practice Meeting ADHB s performance standards Participating in organisation development and performance improvement initiatives Helping to develop and maintain Maori capability in ADHB, including developing our understanding of the Treaty of Waitangi and ways in which it applies in our work Raising and addressing issues of concern promptly THE EMPLOYER AND EMPLOYEE RELATIONSHIP We have a shared responsibility for maintaining good employer/employee relationships. This means: Acting to ensure a safe and healthy working environment at all times Focusing our best efforts on achieving ADHB s objectives A performance agreement will be reached between the employee and their direct manager and/or professional leader containing specific expectations. CONSUMER/CUSTOMER/STAKEHOLDER COMMITMENT All employees are responsible for striving to continuously improve service quality and performance. This means: Taking the initiative to meet the needs of the consumer/customer/stakeholder Addressing our obligations under the Treaty of Waitangi Involving the consumer/customer/stakeholder in defining expectations around the nature of the services to be delivered and the timeframe Keeping the consumer/stakeholder informed of progress Following through on actions and queries Following up with the consumer/customer/stakeholder on their satisfaction with the services PROFESSIONAL DEVELOPMENT As the business of ADHB develops, the responsibilities and functions of positions may change. All staff are expected to contribute and adapt to change by: Undertaking professional development Applying skills to a number of long and short term projects across different parts of the organisation Undertaking such development opportunities as ADHB may reasonably require