County of Simcoe Long-Term Care (LTC) Homes Resident Assessment Instrument Long-Term Care Facilities (RAI-LTCF) Coder, under the guidance of the RAI Coordinator, will accurately gather and translate information about residents in LTC into standardized interRAI LTCF assessment codes, using information from clinical records and interviews with residents and staff.
RAI-LTCF is a standardized provincial electronic assessment used to determine resident status, and supplies information to quality indicators used to establish funding for LTC based on resident needs.
Key responsibilities of this role include understanding the RAI-LTCF assessment instrument and associated best practice; completing all routine resident assessments following those practices; consult with various data sources including PointClickCare (PCC), Point of Care (POC), and facility user defined clinical assessments to correctly code specific sections of the LTCF; and work to ensure data accuracy and data reflect current resident status.
As a valued member of Long-Term Care and Seniors Services, the RAI-LTCF Coder demonstrates a commitment to resident safety by providing quality services in accordance with the organization’s mission and vision.
DATA COLLECTION
1. Gather data from multiple sources, including clinical records, POC documentation, facility user defined clinical assessments, and through interviewing residents and staff on a resident’s functional ability, clinical status, and care needs.
2. Liaise with staff to gather information on the resident, ensuring data collected is accurate and comprehensive.
3. Support the RAI Coordinator to ensure all routine resident RAI-LTCF and the User Defined Assessment (UDA) schedule is developed and maintained.
CODING
4. Translate the collected clinical information into the appropriate codes within the interRAI LTCF assessment tool, applying current coding standards to assessment findings.
5. Ensure that current conditions are coded accurately as per best practice, within designated time frames.
6. Complete coding of routine resident RAI-LTCF assessments as per schedule, in preparation for submission via IRRS.
7. Complete coding assessments as per legislative requirements, on admission, significant change, discharge, return RAI-LTCF as required.
DATA QUALITY
8. Utilize RAI-LTCF assessment outcomes to ensure alignment with resident’s care plans, auditing, and updating plans in a timely manner.
9. Work with the RAI Coordinator to improve processes that ensure data accuracy, efficient data collection, and user defined assessment completion.
10. Contribute to the accuracy and consistency of the data by following coding standards and protocols.
Assist RAI Coordinator with auditing and validation of RAI-LTCF coding.
REPORTING
Support the RAI Coordinator by generating RAI-LTCF reports and facilitating their use in clinical and operational decision-making for quality management purposes.
EDUCATION
11. Support the RAI Coordinator to provide Relias education training and testing within the Home.
12. Attend all Long-Term Care Homes RAI-LTCF assessment education sessions, data submission training by CIHI, AIS, and any other related training requirements.
13. Complete all Relias training and testing required by RAI Coders.
OTHER
14. Serve as back-up to the RAI Coordinator as needed, by monitoring assessment schedules, completing RAI-LTCF audits, and completing the RAI-LTCF weekly submissions.
15. Follow all safe work practices and procedures and immediately communicate any activity or action which may constitute a risk to resident safety.
16. Perform other duties as assigned, including redeployment in emergency situations.
17. Work in compliance with the Occupational Health & Safety Act and the Long-Term Care Homes Act, and their regulations in performing duties in a safe manner and follows all County of Simcoe Health & Safety policies, procedures and legislation.
18. Maintain confidentiality in accordance with the Municipal Freedom of Information and Protection of Privacy Act and the Personal Health Information Protection Act.
Has knowledge of and demonstrated ability in our corporate competencies:
- Acts with the Customer in Mind
- Ensures Accountability
- Continuously Seeks to Improve Work Processes
- Collaborates
- Communicates with Impact
- Is Resilient
- Degree or recognized certificate in a health-related field (e.g., public health, health sciences, physiotherapy, paramedicine, nursing, etc.). This job may be considered for educational equivalency in accordance with County Policy.
- Degree or postgraduate certificate in research, data analysis, epidemiology, or a related discipline would be a asset.
- Current RAI-LTCF Credential and/or completion of all CIHI RAI-LTCF training certification is considered an asset.
- In-depth understanding of the interRAI Long-Term Care Facilities (LTCF) assessment instrument and its underlying principles
- Strong assessment skills and knowledge of the health care industry
- Demonstrated ability to analyze and interpret complex medical information from various sources.
- Strong communication skills to interact with Residents and staff
- Meticulous attention to detail to ensure accurate coding and data entry
- Criminal Records Check with Vulnerable Sector Screening that is less than six (6) months old at time of hire.
- As a condition of employment, candidates are required to submit documented results of TB testing, as per Public Health requirements.
- Valid G class drivers license and access to reliable vehicle.
- A minimum of one (1) year clinical, data analysis, data entry experience.
- Proven ability to meet required deadlines.
- Well-developed oral and written communication skills.
- Well organized, with excellent time management skills.
- Strong aptitude for detail-oriented work.
- The ability to work with and relate to clinical team members and other internal stakeholders.
- Strong problem-solving abilities.
- Display a caring and respectful attitude toward our residents, families, and team members.
- Demonstrable experience collecting, analyzing, and interpreting data.
- Knowledge of relevant policies, procedures, legislation, regulations and best practices applicable to the long-term care sector (e.g. RAI processes and CIHI) is considered an asset.
- Mental and visual effort required when preparing reports, reviewing data and statistics, etc.
- This position is in a long-term care facility, exposure to illnesses and germs are possible daily.
- Ability to work remotely if required.
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