Job Description - Clinical Information Specialist - On Site
Responsibilities and Duties:
Participate in the implementation and support of clinical systems. Ensure maximum use and efficiency of clinical systems.
Provide direct, hands-on education and support to staff in the use of technology in a manner which promotes patient safety and confidentiality.
Consistently strive to improve knowledge and skills in the development of clinical systems and processes.
Provide system support to all end-users including all shifts as needed.
Actively participate in testing and validation of departmental systems and components.
Serves as a super user/clinical expert in use of hospital technology.
Use audit tools and assist in the development of mechanisms to identify and address user adoption issues.
Provide direct hands-on training for department staff in the use of computer hardware, software, and related processes, including adherence to HIPAA and privacy policies.
Serve as a liaison between the department, Crouse or Programmer, and IT in order to resolve system/interface problems.
Conduct audits and report out audit findings to Corporate Compliance Coordinator/Clinical IT Manager
Other duties as assigned by their supervisor, manager or director.
Facilitates appropriate clinical documentation to support the severity of illness and complexity of care rendered to patients.
Concurrently reviews records to identify unclear, ambiguous or inconsistent documentation. Initiates verbal and/or written physician queries and conducts all necessary follow up.
Advises clinicians on the value of reliable, precise, complete, consistent, clear and timely documentation.
Identifies improvement opportunities for system functionality; creates efficiencies and communicates opportunities for improvement
Assures record consistency among admission order, record description of medical necessity and patient status
Functions as an expert source for information regarding the impact of documentation on patient care and severity of illness
Qualifications:
Current New York State licensure as a Registered Nurse, or a Licensed Practical Nurse.
Minimum 3 years of clinical experience.
Strong Computer Skills. Proficient with Windows applications.
Excellent organizational and presentation communication skills
Ability to work effectively individually and as part of a collaborative team.
Ability to work on several complex issues at the same time.
Professionalism and an ability to manage stressful situations in a manner that is conducive to finding resolution.
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