Clinical Documentation Specialist in Grand Rapids, Michigan at Mary Free Bed Rehabilitation Hospital

Summary

The Clinical Documentation Specialist works collaboratively with the nursing division to provide support of the clinical information systems throughout the hospital. Participates in problem solving issues related to clinical information and supports the maintenance of the clinical information system. Participates in the initial and ongoing design and implementation of the clinical information system as it pertains to clinical practice. Due to expertise in the electronic medical record, the CDS also provides support in all areas of documentation for both licensed and unlicensed staff to meet accreditation requirements and maintain patient safety. CDS collaborates with Clinical Educators to provide new hire and continuous education.

Essential Job Responsibilities

• Clinical Required: Provide patient care, treatment, and services within the scope of their license, certification or registration and as required by Federal and State laws and regulations.
• Monitors, evaluates, and reports performance on key quality indicators including but not limited to fall prevention, skin breakdown prevention, pain documentation/control, and restraint usage.
• Develops strong partnerships with the Nursing Leadership team to drive evidence-based practice initiatives that support improved patient outcomes.
• Monitors compliance in best practice initiatives through chart audits, regular report gathering and analyzing data, and manual tracking as needed.
• Serves as the subject matter expert when appropriate to support the documentation of evidence-based policies, procedures, and protocols for the nursing division.
• Provides support to the interprofessional healthcare team to develop, implement and evaluate new patient care programs and outcome goals specific to the patient population.
• Provides electronic medical record training to clinical new hire staff.
• Collaborate with Clinical Educators to provide Nursing New Hire orientation and education as needed.
• Collaborates with internal and external analysts to optimize EMR operations with the goal of improving documentation efficiency.
• Supports the staff at Mary Free Bed with new changes to the electronic medical record by reinforcing education and providing at-the-elbow assistance as needed.
• Supports staff competency regarding documentation to assure that the documentation meets regulatory and accreditation requirements and is in alignment with recognized standards of care and best practice benchmarks.
• Serves as a resource for all nursing staff to support for documentation that meets compliance and regulatory standards.
• Provides occurrence report support for Nursing Leadership, including in-depth chart reviews for regulatory and quality needs.
• All other duties as assigned
• Embrace Diversity, Equity and Inclusion, by:

Treating everyone with dignity and respect

Opening more doors to opportunities for underrepresented cultures

Growing talent and people

Evaluating and eliminating disparities

Taking action against injustices, bias and racism

Honoring our differences and how to collaborate

Educating staff, patients and the communities we care for

Restoring Hope and Freedom, together

Customer Service Responsibilities

Demonstrate excellent customer service and standards of behaviors as well as encourages, coaches, and monitors the same in team members. This individual should consistently promote teamwork and direct communication with co-workers and deal discretely and sensitively with confidential information.

Responsibilities in Quality Improvement

Contribute by identifying problems and seeking solutions. Promote patient/family satisfaction where possible; participates in departmental efforts to monitor and report customer service.

Essential Job Qualifications

• Licensure Requirements: Registered Nurse
• Education RN
• Current Basic Life Support (BLS) certification
• Experience:
  • Must have 2-5 years of relevant nursing experience.
  • Must be proficient in clinical nursing documentation in an electronic medical record. Specific training in clinical informatics is preferred but not required.
  • Proficient computer skills: Microsoft Office programs
  • Strong critical thinking, decision-making, delegation, and leadership skills are required.
  • Time management and organizational skills are required
  • Effective verbal and written communication skills.
  • Ability to meet deadlines, problem solving skills, and handling interruptions
• Due to possible exposure to blood-borne pathogens and hazardous materials, must be able to understand and follow department policies related to employee safety.
• Must be competent with computer systems for documenting patient care.

Preferred Job Qualifications

• Education: Registered Nurse B.S.N.
• Epic for the Clinical Informaticists certification – Have EPIC Credentialed Trainer or Super User Training or will obtain within 12 months of hire

Physical Requirements for Essential Job Qualification

Levels:

• None (No specific requirements)
• Occasionally (Less than 1/3)
• Frequently (1/3 to 2/3)
• Majority (More than 2/3)

Remain in a stationary position: None

Traverse or move around work location: None

Use keyboard: Frequently

Operate or use department specific equipment: Occasionally

Ascend/Descend equipment or ladder: None

Position self to accomplish the Essential Functions of the role: Frequently

Receive and communicate information and ideas for understanding: Frequently

Transport, position, and/or exert force:

Up to 10 pounds: None

Up to 25 pounds: None

Up to 50 pounds: None

Up to 75 pounds: None

More than 100 pounds: None

Other weight: Up to___ pounds _____

Other: _____

The above statements are intended to describe the general nature and level of work being performed by employees in this classification. If you require a reasonable accommodation to perform the essential functions of this position, you must request accommodation in writing, within 182 days after you know or should know of the need for accommodation.

Mary Free Bed is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, national origin, age, genetic information, veteran status, disability or other legally protected characteristic.