Clinical Records Evaluator

Primary Purpose

The Clinical Records Evaluator is responsible for the initial vetting, verifying, reviewing, and assessing of medical documentation from registered health professionals to determine employee’s eligibility for workplace accommodations, medical leaves, and other disability-based exemptions. This includes ensuring an employee’s medical documentation and accommodation/medical leave application package is complete, which may involve following up with the employee and/or relevant health care professionals. The incumbent will ensure compliance with provincial human rights legislation and industry standards by using clinical judgement to design an initial individualized accommodation plan that ensures the University of Waterloo is fulfilling its legal duty to accommodate. As a subject matter expert on the duty to accommodate, the Clinical Records Evaluator determines whether the University has the duty to accommodate and then determines eligibility for accommodations based on clinical records. The incumbent oversees compliance and mitigates risk, with the University’s responsibilities under the Ontario Human Rights Code (OHRC) and its regulations.

The incumbent provides leadership to the occupational health nursing team in regard to analysis and interpretation of clinical records for the purpose of designing workplace accommodation plans for employees registered with Employee Health and Accommodation that uphold legal requirements particularly in challenging, litigious, and/or complex cases. Collaboration with other internal and external campus partners is critical to providing holistic support to employees.

Key Accountabilities

Medical/Clinical Documentation Review (analysis and interpretation)

• Conducts the initial review of all clinical records (medical/habilitative documentation and test results) from registered health professionals submitted by employees seeking accommodations from Employee Health and Accommodation office.
• Analyzes and assess clinical records to develop the employee’s initial workplace accommodation plan as well as determine eligibility for funding opportunities and other exemptions.
• Determines if clinical records are incomplete, inconsistent, or suspicious and seek clarification from registered health professionals and other members of the circle of care as appropriate to ensure accuracy of information, accountability and integrity (with employee informed consent).
• Makes recommendations to registered health professionals regarding the need for additional evaluations.
• Extracts information from clinical records to provide a clinical assessment and recommendations that supports the development of an employee’s workplace accommodation plan.
• Provides leadership in interpretation and application of assessments and documentation to cross- campus units (when needed).

Leadership in Accommodation Planning

• Provide expertise and leadership to the team in regard to analysis and interpretation of clinical records for the purpose of designing workplace accommodation plans.
• Designs the initial accommodation plan for the occupational health manager and case manager.
• Provides clinical record support to the team when managing accommodation disputes and accommodation plan adjustments, particularly when additional medical documentation is required.

Ongoing Consulting on Complex Disability-related Issues/Needs

• Consulting with employees receiving or seeking workplace accommodations and advising around complex issues related to specific disabilities.
• Working closely with other units (e.g., Human Resources) to provide holistic care and support for employees with disabilities in crisis or requiring additional support.
• Using clinical judgement to refer employees to on and off campus support services, including referrals to health care practitioners.
• Consulting with employees seeking to appeal accommodations on the basis of disability. Using clinical judgement to make recommendations to instructors/department regarding these issues.

Developing and Facilitating Workplace Accommodations

• Conducting bio-psycho-social interviews with employees to determine how their functional limitations influence a need for workplace accommodation
• Using medical documentation, clinical judgement, provincial legislation, and standards of practice to design appropriate and individualized workplace accommodation plans on a temporary or ongoing basis
• Counselling employees on workplace accommodations as it relates to their disability
• Screening (for suspected disabilities learning disabilities, mental health and ADHD) and making referrals to appropriate services
• Ongoing clinical assessments of employees to determine any changes in condition and accommodations requirements as well any identification of any internal/external supports
• Provides consultation between the employee, their manager, and other campus partners regarding the provision of accommodations and support.
• Mitigating legal risk by ensuring compliance through consultation, guidance and feedback.
• Generate accommodation summaries for employees upon request.
• Using clinical judgement to consider (and mitigate) the implications of other variables on the accommodation process.
• Working with employees to design and implement appropriate workplace accommodation plans on a temporary or ongoing basis.

Handling Sensitive Materials

• Organize and direct the return of clinical records to the intended party in a secure manner (appropriate storage and movement of confidential documents).
• Ensure access to secure documents are controlled appropriately.
• Ensure data accuracy and document integrity.
• Appropriately use and maintain confidential health and education records in accordance with University policy and relevant Privacy legislation.
• Effectively uses systems and technology to accurately and efficiently manage employee medical documentation.

Collaborating with Partners and Key Stakeholders

• Consult with campus partner (departments/units) to understand their documentation-review needs and to determine a documentation review process that is streamlined and efficient.
• Consult with employees to facilitate their application or submission for exemption, accommodation, etc., on behalf of campus partners.
• Consult with campus partners related to employee accommodations or exemption applications, and to offer guidance and advice regarding specific issues as they arise.
• Communicate and collaborate with various cross-campus partners to review processes regularly and ensure quality.
• Develop and leverage positive relationships with appropriate on and off campus stakeholders.
• Provide proactive, professional and effective communications strategies with employees registered with the office.
• Utilize proactive, professional and effective communication strategies with employees registered with Employee Health and Accommodation and other key stakeholder as appropriate.

Required Qualifications

Education

• Graduate degree in either Rehabilitative Health Sciences (e.g., Occupational Therapy), Nursing, Social Work, Psychologist, or related field.
• Eligible for registration with a professional college/society recognized in Ontario.

Experience

• Experience reviewing medical documentation, psycho-educational assessments, and habilitative documentation and test results from registered health professionals to determine a support plan.
• Experience in an employee-focused (secondary or post-secondary school context) environment.
• Experience providing accommodations, support, or services to persons with disabilities.
• Experience and/or training in supporting persons in crisis and securing appropriate support.

Knowledge/Skills/Abilities

• Working knowledge of privacy regulations.
• Strong understanding of how symptoms or functional limitations of a disability interferes with an individual’s daily functioning.
• Proven ability to work independently and as a team member in a busy and inter-disciplinary environment.
• Excellent communication (oral and written) skills.
• Superior organizational, problem-solving and interpersonal skills required.
• Proven ability to provide solution-focused interventions.
• Negotiation and mediation skills is an asset.
• Basic knowledge of MS Word, Excel, and PowerPoint
• Familiarity using databases for case management.