HNHB Local Health Integration Network

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Permanent Full Time Health Records Specialist

Permanent Full Time Health Records Specialist

Competition Number 
Position Group 
Closing Date 
Length of Term 
n/a - PERM
Hours of Work 
Monday to Friday, 8:30am to 4:30pm
OPSEU - E: $30.86 - $36.14 per hour

More information about this job

Position Summary

Develops and maintains policies and procedures for patient records that ensure legislative compliance and reflect quality standards.  Responds to all requests for release of information from patient records.  Responsible for conducting quality improvement audits of patient records, including individualized focused audits, to ensure compliance with policies and procedures Provides consultation and education to managers and staff related to maintenance of patient records quality standards and processes related to release of information as per applicable legislation. Supports the integrity of the patient record by modifying/correcting the patient record in accordance with LHIN policies and procedures, applicable legislation & assignment within the Health Records Specialist role. As a Health Information Management Professional, provides Primary Diagnostic and Surgical Procedure Coding of LHIN patients at admission as well as new or updated diagnoses or procedures at reassessment.

Core Duties - Responsibilities

Policies and Procedures

  • Develops and maintains policies and procedures related to quality of patient records to ensure compliance with legislative requirements and accreditation standards
  • Reviews and recommends revisions to organization’s policies and procedures related to patient records management processes (e.g. chart order, documentation standards, retention guidelines)

Release of Information

  • Responds to requests for release of patient information received from patients, their authorized representatives, or other third parties (e.g., lawyer, coroner, police, insurance company, government, Veterans Affairs, Workers Compensation Board), complying with LHIN policies and procedures and relevant legislation (e.g., PHIPA), which includes:
  • determining the validity of each request for release of information
  • ensuring appropriate consent for release of information is obtained
  • ensuring extraction and preparation of all relevant information for release
  • consultation with the LHIN Privacy Officer as necessary
  • Provides consultation and education to managers and staff related to release of patient information and relevant legislation

Chart Audits

  • Supports the development and implementation of quality improvement audits related to patient records
  • Conducts quality improvement audits related to patient records to ensure organizational compliance with relevant records-related policies and procedures
  • Develops, with input from Patient Care, the frequency and type of audits required to ensure standardized documentation

Diagnostic and Procedure Coding

  • Consistently codes all Diagnoses and Procedures for each referral of the LHIN using ICD-9 coding, and in future, using ICD-10 utilizing the LHIN patient data base
  • Accurately codes any new or updated diagnoses or procedures at reassessment in a timely manner
  • Ensures quality and accuracy of Diagnosis and Procedure codes and that these accurately capture Special Patient Groups at the Referral Level in the LHIN patient database
  • Provides consultation on diagnosis and procedure codes for data extracts to reflect special target groups


  • Participates in relevant internal and external committees as required
  • Identifies own learning needs required to support and maximize a quality patient records management service
  • Leads and/or participates in and demonstrates an understanding of quality, risk and patient safety principles and practices.
  • Follows all safe work practices and procedures and immediately communicates any activity or action which may constitute a risk to quality, and patient safety
  • Performs other duties as required/assigned

Patient Safety

  • Promotes patient safety in alignment with the Vision, Mission, Values and Strategic Directions of the LHIN
  • Works within the basic principles of patient safety by doing the right thing for the right patient, using the right method at the right time
  • Adheres to LHIN’s patient safety policies and procedures



  • Graduate of a recognized diploma or degree program in Health Information Management
  • Holds current certificate of registration with the Canadian College of Health Information Management, (CHIM) with Active membership in CHIMA

Preferred Experience

  • Minimum 3 years current experience in a related position

Skills & Abilities

  • Sound knowledge of legislation (e.g., Personal Health Information and Protection Act) and practices pertaining to privacy/confidentiality, security of patient information, and patient records management
  • ICD-9 coding experience
  • ICD-10 coding experience preferred
  • CCP (Canadian Classification of Diagnostic, Therapeutic, and Surgical Procedures) coding experience
  • Proficiency in computer software applications (e.g., Microsoft Office Suite)
  • Experience in release of information, with information access and privacy training preferred
  • Experience in working with cross sector/intra organizational teams
  • Demonstrated ability to develop, design and implement reports
  • Demonstrated analytical skills
  • Ability to develop and present related educational modules/workshops
  • Highly organized and detail oriented
  • Strong confidentiality, interpersonal and time management skills
  • Excellent verbal and written communication skills
  • Experience with development of policies and procedures and statistical software packages are assets



  • Valid “G” driver’s license and access to a vehicle for potential travel within HNHB LHIN region.


Applications will be considered on an ongoing basis - so apply today!


NOTE: This a unionized role through OPSEU (Ontario Public Services Employees Union) - the starting rate for this role is $30.86/hour (firm) along with a comprehensive benefits package and Pension through HOOPP (Healthcare of Ontario Pension Plan).