POSITION - mercycq.com Coder Mater... · Observation, Coder audit results, feedback 1.1.2 Applies...
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POSITION SPECIFICATIONS Position Title: Clinical Coder Job Type: Full-time, Part-time, or Casual Region: Rockhampton, Queensland MH&ACCQL Facility: Mater Misericordiae Hospital - Rockhampton Closing Date: Open until filled Salary: MH&ACCQL – Administration and Support Services – Enterprise Agreement 2015-2016 Reporting to: Director of Nursing/Health Information Strategy Manager ENQUIRIES CONTACT Enquiry Contact: Kylie Keates, Health Information Strategy Manager Email: [email protected] About the Role: Mater Misericordiae Hospital – Rockhampton are seeking enthusiastic and experienced Clinical Coders. Within the current team framework, two tiers of Clinical Coders are being sought: Clinical Coder (CC) The Clinical Coder is responsible for the accurate translation of diseases, injuries and procedures into alphanumeric codes using ICD-10-AM and assignment of AR-DRGs within Mercy Health & Aged Care Central Queensland Limited timeframes. They may not yet be sufficiently experienced to be able to code the all specialties relevant to the hospital at which they are based or may be required to code for remotely. The Clinical Coder may be required to work with the Clinical Documentation Specialists (CDS) for the hospitals where the CDS role exists. MH&ACCQL - Administration and Support Enterprise Agreement Classification: Level 4 - Currently attracting an hourly rate range of $32.47-$33.69 Intermediate Clinical Coder (ICC) The Intermediate Clinical Coder meets the requirements of the Clinical Coder level AND the Intermediate Clinical Coder level. Clinical Coders of this level are able to code all specialities relevant to the hospital at which they are based and any MHACCCQL hospital they may be called upon to code for either onsite or remotely. They are also capable of completing a number of quality activities, and may be required to assist the Coding Coordinator with internal coding audits.
Transcript of POSITION - mercycq.com Coder Mater... · Observation, Coder audit results, feedback 1.1.2 Applies...
POSITION SPECIFICATIONS
Position Title: Clinical Coder
Job Type: Full-time, Part-time, or Casual
Region: Rockhampton, Queensland
MH&ACCQL Facility: Mater Misericordiae Hospital - Rockhampton
Closing Date: Open until filled
Salary: MH&ACCQL – Administration and Support Services
– Enterprise Agreement 2015-2016
Reporting to: Director of Nursing/Health Information Strategy
Manager
ENQUIRIES CONTACT
Enquiry Contact: Kylie Keates, Health Information Strategy Manager
Email: [email protected]
About the Role: Mater Misericordiae Hospital – Rockhampton are seeking enthusiastic and experienced Clinical Coders. Within the current team
framework, two tiers of Clinical Coders are being sought:
Clinical Coder (CC) The Clinical Coder is responsible for the accurate translation of diseases,
injuries and procedures into alphanumeric codes using ICD-10-AM and
assignment of AR-DRGs within Mercy Health & Aged Care Central Queensland Limited timeframes. They may not yet be sufficiently
experienced to be able to code the all specialties relevant to the hospital at which they are based or may be required to code for remotely. The Clinical
Coder may be required to work with the Clinical Documentation Specialists (CDS) for the hospitals where the CDS role exists.
MH&ACCQL - Administration and Support Enterprise Agreement Classification: Level 4 -
Currently attracting an hourly rate range of $32.47-$33.69
Intermediate Clinical Coder (ICC)
The Intermediate Clinical Coder meets the requirements of the Clinical Coder level AND the Intermediate Clinical Coder level. Clinical Coders of
this level are able to code all specialities relevant to the hospital at which they are based and any MHACCCQL hospital they may be called upon to
code for either onsite or remotely. They are also capable of completing a
number of quality activities, and may be required to assist the Coding Coordinator with internal coding audits.
Mercy Health & Aged Care Central Queensland Limited
The Intermediate Clinical Coder has additional responsibilities and skills in
relation to the following: Coding accuracy targets
Clinical coding expertise including complex coding & the provision of coding advice
DRG allocation accuracy assurance Coordinating coding quality activities among the coders of all
levels
Breadth of clinical coding expertise Data interpretation, including the resolution of data validation
errors Orientation and training of new staff
In-service training and education for coding staff In-service training and education for clinical staff
Attendances: HICC, QCC, Casemix and other committees, if required as a proxy for the Coding Coordinator.
MH&ACCQL - Administration and Support Enterprise Agreement Classification: Level 5 -
Currently attracting an hourly rate range of $39.41-$39.82
A Clinical Coder Competency Framework is available following
these specifications.
If you are interested and wish to explore working within a caring,
compassionate setting focused on excellence in patient care and employee experience then contact Kylie Keates, Health Information Strategy
Manager. Alternatively, head to our website at
https://www.mercycq.com/mh/careers and submit an application or make an enquiry about the role.
Mercy Health & Aged Care Central Queensland Limited
Clinical Coder Competency Framework v4 Page 1 of 10
1 Clinical Coder Competency Framework – KPIs are indicative only
1.1 Competency Area 1 – Technical
# Competency Level Applies to Assessment Methodology
TCC CC ICC CCo
1.1 Clinical Coding Process
1.1.1 Follows all steps within the clinical coding process when coding each episode.
Observation, Coder audit results, feedback
1.1.2 Applies detailed knowledge of anatomy, physiology, pharmacy, medical terminology, disease processes and procedural knowledge in interpretation of health record information.
Coder audit results, ad hoc review
1.1.3 Efficiently and effectively abstracts relevant information from the record regardless of whether it be paper, electronic, or a combination format.
Observation, Coder audit results, productivity results, ad hoc review
1.1.4 Investigates new or unfamiliar diseases, clinical interventions, and procedures to ensure accurate code assignment.
Observation, Coder audit results
1.1.5 Identifies cases of inadequate documentation in the health record and takes appropriate measures to access missing information &
Observation, Coder audit results, Coding query register
Mercy Health & Aged Care Central Queensland Limited
Clinical Coder Competency Framework v4 Page 2 of 10
# Competency Level Applies to Assessment Methodology
TCC CC ICC CCo
clarify ambiguous documentation with clinicians.
1.1.6 Seeks assistance from other peers, CDS and Clinicians and relevant references when coding unfamiliar content
Observation, feedback
1.1.7 Applies the Australian Coding Standards, ACCD, QCC coding advice in all circumstances, and adhere to the Ethics for Clinical Coders.
Coder audit results, validation reports
1.1.8 Achieves appropriate DRG generation representative of episode complexity and services provided.
Observation, Coder audit results
1.2 Coding Accuracy / Competency
1.2.1 Meets the coding accuracy targets for the level as per table for the annual Individual Clinical Coder audit performed
Coder audit results
1.2.2 Competently codes all specialties relevant to the hospital in which they are primarily located and to other MH&ACCQL sites where coding is covered remotely or via onsite visit.
Coder audit results, peer review
1.2.3 Demonstrates advanced coding ability and expertise
Conduct coding audits, provision of coding advice
Mercy Health & Aged Care Central Queensland Limited
Clinical Coder Competency Framework v4 Page 3 of 10
# Competency Level Applies to Assessment Methodology
TCC CC ICC CCo
1.2.4 Provides expert clinical coding advice and support to Clinical Coders and CDS.
Observation, mentoring
Coder Audit Accuracy Requirements:
Trainee CC Clinical Coder Intermediate CC CCoordinator
Appropriate DRG assignment 80% 85% 90% 95%
Principal Diagnosis (based on coder error only) 80% 85% 90% 95%
Additional Diagnoses/Procedures (based on coder error only)
80% 85% 90% 90%
1.3 DRG Grouping / Casemix
1.3.1 Follows all steps within the clinical coding process when grouping each episode to assess the appropriateness of the DRG.
Observation, use of DRG software
1.3.2 Demonstrates knowledge and insight into DRG assignment logic and inpatient Casemix principles. The level of knowledge and insight increases with experience and coder level.
Explanation of DRG derivation, use of DRG software, explanation of DRG triggers.
Mercy Health & Aged Care Central Queensland Limited
Clinical Coder Competency Framework v4 Page 4 of 10
1.4 Coding Notifications and Associated Collections
1.4.1 Complete coding in accordance with documented procedure, and other mandatory notifications as required.
Minimal validations attributable to Coder returned from
statutory collections such as Queensland Health, Hospital Casemix Protocol, and Private Health Data Bureau.
1.4.1 Completes electronic cancer registrations in accordance with the documented procedure, and other mandatory notifications as required.
Minimal cancer registry validations returned for Coder
1.5 Ward Based and Cross-Complex Coding
1.5.1 Is able to adapt to changing Coding Service and coding priorities including cross campus coding when required.
Observation
1.5.2 Performs ward based coding on a scheduled &/or needs basis.
Ward based coding is performed
1.5.3 Performs coding for outsourced contracts if required.
Outsource coding is performed
1.6 Coding Productivity
1.6.1 Achieves an average coding productivity rate per Coder Level Matrix. Reports factors that contribute to exceptions.
Productivity results over each month
1.6.2 Achieves an agreed % time allocation between coding and non-coding duties as per Coder Level Matrix. Reports factors that contribute to exceptions.
Productivity results over each month
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Clinical Coder Competency Framework v4 Page 5 of 10
1.6.3 Daily productivity statistics are as captured by the Coding Module of the patient management system, and the Coder notifies the Coding Coordinator/ Health Information Strategy Manager if there are factors that prevent the achievement of agreed productivity rates.
Coding reports/extracts from patient management system
1.6.4 Applies appropriate time management and workload prioritisation skills at all times.
Observation
1.6.5 Codes all episodes irrespective or complexity or length of stay
Observation, coding reports/extracts from patient management system
1.2 Competency Area 2 – Data Management
# Competency Level Applies to Assessment Methodology
TCC CC ICC CCo
2.1 Patient Management and Related Information Systems
2.1.1
Competently uses electronic systems to assist in code verification & allocation.
Observation
2.1.2 Competently uses the coding module within webPAS
Observation
2.1.3 Uses Microsoft Outlook daily and Microsoft Word, Excel and Power Point as required.
Observation
Mercy Health & Aged Care Central Queensland Limited
Clinical Coder Competency Framework v4 Page 6 of 10
# Competency Level Applies to Assessment Methodology
TCC CC ICC CCo
2.1.4 Searches and locates relevant information on the Intranet and Internet to assist in accurate code assignment.
Observation
2.1.5 Reports system issues that impact on coding timeliness or accuracy
Observation
2.1.6 Identifies potential issues with system updates and upgrades, logs system defects and tests new functionality as required.
Observation
2.2 Data Reporting
2.2.1 Corrects/validates data validation errors.
Validation errors are fixed
2.2.2 Resolves validations edit errors in consultation with Coding Coordinator enabling completion of validation reports.
Validation errors are fixed
2.3 Data Reports
2.3.1 Liaises with requesting parties, determines appropriate code search criteria, facilitates approval process and produces reports in accordance with the documented procedure.
Email trail
2.3.2 Reliably interprets and comments on limitations and validity of data results (including the impact
Email trail
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Clinical Coder Competency Framework v4 Page 7 of 10
# Competency Level Applies to Assessment Methodology
TCC CC ICC CCo
of clinical classifications/ coding standards and DRG grouping changes).
1.3 Competency Area 3 – Quality
# Competency Level Applies to Assessment Methodology
TCC CC ICC CCo
3.1 Process Improvement
3.1.1 Identifies areas for improvement in the Coding Service processes
Observation
3.1.2 Participates in the design and implementation of process improvements.
Observation
3.1.3 Provides feedback in relation to current and newly implemented Coding Service processes
Meeting, observation
3.2 Coding Quality
3.2.1 Directs coding quality activities in accordance with the Coding Quality Plan
3.2.2 Participates in coding quality activities in accordance with the Coding Quality Plan
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Clinical Coder Competency Framework v4 Page 8 of 10
# Competency Level Applies to Assessment Methodology
TCC CC ICC CCo
3.2.3 Disseminates coding industry resources when they become available e.g. QCC minutes and query responses, Coding Matters.
Observation, Forum, Meeting, Sharepoint
3.2.4 Reviews queried/audited coding/DRGs and appropriately amends coding if required.
System changes, ICC and Coding Coordinator feedback
3.2.5 Identifies coding practices that are inconsistent within the coding team.
Feedback
3.2.6 Undertakes investigation and appropriate resolution of complex coding cases.
Peer consultation
3.2,7 Documents ‘Coding Queries’ in the appropriate format for submission to the VMOs responsible for responding to Coding Queries.
Coding queries
3.2.8 Records coding queries on the Coder Sharepoint for tracking of completion, including escalation to DON/EO, and identification of trends.
Coding queries register on Coder Sharepoint
3.3 Auditing
3.3.1 Performs targeted auditing for area of expertise in conjunction with the Coding Coordinator or Health Information Strategy Manager.
Feedback
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Clinical Coder Competency Framework v4 Page 9 of 10
# Competency Level Applies to Assessment Methodology
TCC CC ICC CCo
3.3.2 Performs internal auditing for a broad range of clinical specialities/facility morbidity data.
Audit report
3.3.3 Applies sound auditing principles and effectively utilises the agreed auditing tools and process (including sampling).
Audit report
3.3.4 Interprets auditing results contributing to errors to identify areas for improvement
Audit report
3.3.5 Makes key observation re auditing results and factors contributing to errors
Audit report
3.3.6 Provides feedback of auditing results to individuals with sensitivity and objectivity.
Observation, Audit report
3.3.7 Contributes in an agreed format to the audit report prepared by the Health Information Strategy Manager.
Observation, Audit report
3.4 Training and Development
3.4.1 Participates in and completes educational and training workplace activities.
Observation
3.4.2 Reads and applies coding industry updates when they become available e.g. QCC minutes and query responses, Coding Matters.
Observation
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Clinical Coder Competency Framework v4 Page 10 of 10
# Competency Level Applies to Assessment Methodology
TCC CC ICC CCo
3.4.3 Orientates new or introductory Clinical Coders to the Coding environment
Observation
3.4.4 Oversees the orientation and training strategy of new or Trainee Clinical Coders.
Observation, Trainee speciality competency progression
3.4.5 Prepares in-service coding training materials for continuing education and training in conjunction with the Health Information Strategy Manager.
Forum
3.4.6 Presents coding in-service sessions for the Coding service in conjunction with the Health Information Strategy Manager.
Observation
3.4.7 Mentors Clinical Coders in training or in orientation.
Observation
