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Trinity Health MERCY ED CLINICAL DOCUMENTATION SPECIALIST in Springfield, Massachusetts

Collaborates with all clinicians regarding clinical workflow to ensure successful support of technology that benefits patient care, accurately captures regulatory requirements, and achieves expected quality outcomes. Reviews and audits clinical documentation monthly and as needed. Engages staff in coaching and counseling sessions specific to documentation that may result in corrective actions. Partners with Information Technology, Health Information Systems, clinical departments, and other departments across the continuum, to assess use of informatics by clinicians; looks for informatics technology opportunities that impact/improve clinical documentation; improve workflow efficiency and patient quality and safety; and maximize the revenue cycle using informatics and information technology. Assists ED management in data review and reporting to local and regional Senior Leadership. Collaborates in planning, developing, refining and evaluation of clinical documentation training programs. Adheres to project timelines, scope and budget.

Demonstrates commitment to professional growth and competence and current knowledge in healthcare informatics to promote advancement of clinical practice and the provision of quality health care.

Provides ongoing quality/clinical reviews of Emergency Department processes and documentation of services in order to assure accuracy and timely capture of information as needed.

Routinely conducts chart audits; monthly and as needed. Engages staff in coaching and counseling sessions specific to documentation that may result in corrective action.

Recommends quality improvement projects based on data from auditing process.

Networks with informatics professionals internally and/or externally.

Active participation in professional organizations to maintain an awareness of issues impacting health care including IT needs and regulatory requirements for rehabilitation services.

Participates with Emergency Department initiatives throughout the continuum related to quality improvement initiatives. Assists with data collection, analysis, and management of data in order to promote best practice for patient care.

Participates with Emergency Department Leadership team in planning and establishing various initiatives and projects.

Facilitates collection, review and analysis of data related to patient populations and for quality improvement opportunities. Reports data to ED management and local and senior leadership.

Provides oversight of Emergency Department data related to quality and other initiatives, providing assistance and feedback to Emergency Department leadership and staff as needed.

Assists with development and presentation of data as needed to communicate with the Emergency Department and across other entities. To work internally with other departments and across the continuum on various organizational issues and projects.

Maintains up-to-date knowledge related to regulatory bodies and compliance in order to assure compliance. Assists with regulatory issues as they arise.

Represents clinical informatics, information management and computer issues related to the Emergency Department.

Participates actively in Emergency Department departmental and hospital meetings, committees and task forces relative to areas of practice or interest.

Develops and meets quality improvement goals and objectives for the Emergency Department and associated departments and care areas.

Keeps the Emergency Department and Clinical Informatics informed of any unusual concerns or situations relative to user departments and clinical application systems.

Demonstrates ability to use all channels of communication to address inter- and intra-departmental concerns relative to informatics, information management, solve problems, and address conflict.

Maintains patient privacy and confidentiality according to established hospital procedures.

Assesses clinician’s informational needs from each of the various caregiver groups in the Emergency Department perspective on an on-going basis (prior to, during, and after implementation of clinical systems (Emergency staff, Research, Administrative Support, MD/Nursing in collaboration with IT representatives)-Meditech, EPIC).

Monitors quality of information by reviewing and monitoring adherence to clinical requirements and changing healthcare environment and regulations.

Integrates knowledge about clinical process and regulatory requirements into the clinical information systems.

Maintains clinical expertise to evaluate interaction of clinical IS systems to clinical practice as needed for compliance.

Assists Clinical Informatics in the clinical design and configuration of clinical applications and reports for Emergency Department to meet the user identified and approved needs and regulatory requirements.

Coordinates application and end user solutions with Emergency Department, appropriate clinical departments, Emergency Department, service lines and platforms, appropriate HIS departments, and Clinical Informatics.

Performs chart audits and assists on compiling historical trends for educational opportunities with staff.

Participates in Emergency Department planning for clinical information systems to meet Emergency Department information needs. Manages complex projects with minimal direction. Completes assigned tasks as a member of a project team or individually as assigned by director and demonstrates ability to manage multiple projects and assignments concurrently.

Participates in assessing, recommending/selecting and integrating clinical information systems (Meditech, EPIC).

Evaluates the impact of the clinical applications on patient satisfaction and patient outcomes.

Maintains effective communication with users in the department to manage priorities, reports status, and ensure problem resolution.

Collaborates with informatics teams and Clinical Informatics/ Management Team in establishing clinical priorities for Emergency Department related information systems.

Maintains project issue lists, addresses priorities to ensure timely resolution of issues including communicating ongoing status to users, project leaders, managers, and other affected parties including updating project plans when appropriate.


Job Number: 00193729

Location: Springfield, MA

Organization Name: Trinity Health Of New England

Facility: SPMA - Mercy Medical Center

Employment Type: Full time

Shift: Day Shift

Hours: 40