Clinical Documentation Specialist

5 days ago

Markham, Canada SE Health Full time

Clinical Documentation Specialist

Position Summary:

The Clinical Documentation Specialist plays a pivotal role in our organization's digital transformation, leading the transition from paper-based to electronic health records (EHR). This position is responsible for developing and implementing innovative digital documentation strategies that streamline clinician workflows while maximizing data potential. The specialist will ensure the accuracy, completeness, and compliance of clinical documentation within the new EHR system, focusing on optimizing processes that enhance efficiency and support high-quality patient care. By collaborating with healthcare providers, IT staff, and other stakeholders, this role will refine documentation practices to meet regulatory requirements, improve operational efficiency, and facilitate data-driven decision-making. The ideal candidate will combine clinical expertise with a strong understanding of clinical documentation to design documentation workflows that not only ease the clinician's cognitive load but also unlock the full potential of healthcare data for improved patient outcomes and organizational performance.

Responsibilities:

  • Collaborate with the EHR implementation team to design and configure documentation templates and workflows that align with clinical best practices and regulatory requirements
  • Review and analyze current documentation practices, identifying areas for improvement in the transition to electronic documentation.
  • Develop and deliver training programs for clinical staff on effective documentation practices within the new EHR system
  • Conduct regular audits of electronic clinical documentation to ensure accuracy, completeness, and compliance with coding and regulatory standards.
  • Work closely with physicians and other healthcare providers to clarify documentation and address any gaps or inconsistencies in the EHR.
  • Collaborate with the cross-functional teams to resolve documentation and coding discrepancies, ensuring optimal reimbursement in the new digital environment
  • Monitor and analyze EHR documentation metrics, providing feedback to management on areas for improvement and optimization
  • Stay updated on evolving EHR functionalities, documentation best practices, and regulatory changes, incorporating this knowledge into ongoing process improvements
  • Participate in cross-functional teams to address documentation-related challenges during the EHR implementation and post-go-live optimization phases
  • Serve as a subject matter expert on clinical documentation within the EHR, providing guiding both clinical and IT staff.
  • Ensure that documentation practices align with clinical compliance standards and maintain the quality of care.
  • Identify and mitigate risks related to clinical documentation, developing action plans as needed.

Requirements:

  • Bachelor's degree in Nursing, Health Information Management, or related field. Master's degree preferred.
  • Minimum of 5 years of clinical experience. Home Care experience preferred.
  • CCDIS (Certified Clinical Documentation Improvement Specialist) certification or willingness to obtain within one year of hire.
  • Strong knowledge of medical terminology, disease processes, and ICD-10 coding.
  • Extensive experience with EHR systems and digital health technologies.
  • In-depth understanding of clinical documentation regulations and best practices.
  • Excellent analytical and problem-solving skills.
  • Strong communication and interpersonal abilities, with the capacity to effectively interact with various levels of healthcare professionals.
  • Demonstrated ability to lead small to medium-sized initiatives and manage change effectively.
  • Proficiency in data analysis and report generation using tools such as Excel, Tableau, or similar software.
  • Familiarity with quality improvement methodologies such as Lean Six Sigma and their application in healthcare settings.
  • Ability to work independently and as part of a team in a fast-paced environment.

About Us:

At SE, we love what we do. Every day, we bring hope and happiness to clients, homes, and communities across Canada. We treat each person with dignity and love, like our own family; we build empathy; and we do the right thing. We are always inspired to make a difference. As a not-for-profit social enterprise, we share knowledge, provide the best care, and help each client to realize their most meaningful goals for health and wellbeing. We are an inclusive workplace offering competitive pay, benefits, pension, and work life balance. We’re a great place to work, and we hope you’ll join our team.

SE Health is committed to the success of all its employees. If you feel you need accommodations because of illness or disability, please do not hesitate to contact Talent Acquisition Team at careers@sehc.com at your earliest convenience.

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