Clinical Information System Specialist provides on-site technical support to clinicians to ensure the proper and effective use of clinical information systems and improve the delivery of patient care. Assists users with system navigation, troubleshooting and patient monitoring issues. Being a Clinical Information System Specialist collaborates with leaders across functions and disciplines to plan, implement and evaluate the effectiveness of clinical systems and services. Requires a bachelor's degree. Additionally, Clinical Information System Specialist typically reports to a supervisor or manager. The Clinical Information System Specialist occasionally directed in several aspects of the work. Gaining exposure to some of the complex tasks within the job function. To be a Clinical Information System Specialist typically requires 2-4 years of related experience. (Copyright 2024 Salary.com)
GENERAL SUMMARY:
Reporting to the Director of HIM, CDI and Coding, is responsible for improving the overall quality and completeness of clinical documentation. Performs concurrent record reviews on all selected admissions and document findings. Facilitates modifications to clinical documentation to accurately reflect patient severity of illness and risk of mortality through extensive interaction with physicians and mid-level providers, case management, nursing staff, other patient care givers and coding staff.
PRINCIPAL DUTIES AND RESPONSIBILITIES:
1. Initiates and performs concurrent documentation review of selected inpatient records to clarify conditions/diagnoses and procedures where inadequate or conflicting documentation is suspected.
2. Communicates with the individual physician or medical staff departments to facilitate complete and accurate documentation of the inpatient record.
3. Partners with operational and medical leadership in a given service line to identify, develop and implement successful communication and education, to engage physicians and improve processes and outcomes.
4. Rounds daily with physician and mid-level providers to ensure appropriate and accurate documentation in the medical record.
5. Ensures the level of services and acuity of care will accurately be reflected in quality outcomes.
6. Performs data collection activities to identify documentation issues, quality issues and opportunities for improvement in patient care and services.
7. Analyzes quality and patient safety data to identify patterns in the management of patient care and services using reported 1.) Hospital acquired conditions, 2.) Patient safety indicators, 3.) Case Mix Index, and 4.) Expected mortality.
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