Clinical Documentation Specialist

Clinical Documentation Specialist

The Clinical Documentation Specialist plays a crucial role in ensuring that our organization's electronic health records (EHR) meet best practice and regulatory standards. This position is accountable for developing and implementing digital documentation strategies that optimize data capture while minimizing the documentation burden on frontline providers. The specialist will collaborate closely with clinical informaticists and data experts to maximize the organization's data utilization potential.

They will work with frontline staff to identify essential information required for excellent patient care, reviewing it against existing documentation to ensure comprehensive data capture while adhering to regulatory and accreditation standards.

By partnering with IT, the specialist will ensure that the documentation aligns with frontline provider workflows, promoting efficiency and accuracy. Their primary deliverable is the creation of complete and accurate digital clinical records that balance maximum data capture with minimal provider burden.

The ideal candidate will combine clinical expertise with a strong understanding of documentation practices to refine processes that meet regulatory requirements, improve operational efficiency, and facilitate data-driven decision-making. This role is essential in optimizing the EHR system to support high-quality patient care and enhance organizational performance through improved data utilization.

Key Responsibilities:

• Lead the design and configuration of EHR documentation templates and workflows, ensuring alignment with clinical best practices and regulatory requirements.
• Analyze and optimize current documentation practices, identifying areas for improvement in the transition to electronic documentation.
• Coordinate all issues that arise in the clinical documentation application area, including software updates, changes, and potential system enhancements.
• Review and test each new software release, ensuring it meets organizational needs and regulatory standards.
• Develop and deliver training programs for clinical staff on effective EHR documentation practices, participating in end-user training and troubleshooting.
• Conduct regular audits of electronic clinical documentation to ensure accuracy, completeness, and compliance with coding and regulatory standards.
• Collaborate with healthcare providers and cross-functional teams to clarify documentation, address gaps or inconsistencies, and resolve coding discrepancies.
• Analyze data conversion needs and ensure that data coming across interfaces meets business requirements.
• Develop and document project team procedures for implementing system changes and other tasks related to clinical documentation.
• Set standards for naming and numbering conventions and security classifications in line with organizational guidelines.
• Work with report writers to ensure the application has necessary reports for monitoring and analyzing EHR documentation metrics.
• Stay updated on EHR functionalities, documentation best practices, and regulatory changes, incorporating this knowledge into ongoing process improvements.
• Serve as a subject matter expert on clinical documentation within the EHR, guiding both clinical and IT staff.
• Identify and mitigate risks related to clinical documentation, developing action plans as needed.

Key Skills and Attributes:

• Strong project management, organizational, and communication skills
• Ability to lead meetings, prioritize tasks, and manage conflicts
• Capacity to understand and address the underlying needs of the organization and user community
• Proficiency in reviewing and analyzing software applications
• Eagerness to learn and promote the EHR system within the organization
• Ability to work effectively with project leadership and subject matter experts

Qualifications:

Education:

• Bachelor's degree in nursing, Health Information Management, Clinical Discipline, Health Informatics, or related field. Master's degree preferred.

Experience:

• Minimum 5 years of clinical experience, preferably in a hospital setting.
• Extensive experience with EHR systems and digital health technologies.
• Previous experience with EHR implementation is highly desirable.

Knowledge and Skills:

• Strong knowledge of medical terminology, disease processes, and ICD-10 coding.
• In-depth understanding of clinical documentation regulations and best practices.
• Proficiency in data analysis and report generation
• Familiarity with quality improvement methodologies (e.g., Lean Six Sigma) in healthcare settings.
• Proficient in Microsoft Office tools (Excel, Word, PowerPoint); Visio experience an asset.

Competencies:

• Excellent analytical and problem-solving skills.
• Strong communication and interpersonal abilities to interact effectively with various levels of healthcare professionals.
• Demonstrated ability to lead initiatives and manage change effectively.
• Ability to work independently and as part of a team in a fast-paced environment.
• Innovative, results-oriented, and detail-focused approach.
• Capacity to learn, understand, and apply new technologies quickly.
• Ability to effectively prioritize and execute tasks in a high-pressure environment.

About SE Health

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.

In the interest of the health and safety of our patients/clients, employees, and greater good of public health, SE Health requires those that wish to work for this organization to be fully vaccinated against COVID-19. Fully vaccinated means a person has received both doses of the COVID-19 vaccine and it has been 14 days since the last dose.

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 the Talent Acquisition team at careers@sehc.com at your earliest convenience.