Clinical Documentation Specialist
- Toronto, ON, Canada
Full-time
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Job details
- Job type
- Full-time
- Apply by
- Posting language
- English
- Posted
Original job description
Overview
The Clinical Documentation Specialist ensures the accuracy, completeness, timeliness, accessibility, confidentiality, and integrity of the health record. The role combines health information management and clinical documentation practices with specialized quality assurance, report distribution, documentation-completeness monitoring, and clinician workflow support. This role involves close collaboration with physicians and residents to offer training for clinical documentation dictation, optimize clinical documentation integrity, and facilitate quality patient care.
EDUCATION
Michael Garron Hospital (MGH) champions accessibility, diversity and equal opportunity through the creation of an inclusive and diverse work environment. At Michael Garron Hospital, we strive to be an equitable and inclusive employer. We encourage candidates from Black, First Nations, Métis and Inuit, racialized and LGBTQ2S+ communities, people of colour, women, people with disabilities and individuals who identify with the diverse communities that we serve, to join the MGH team.
Through our values of Compassion, Respect, Integrity, Inclusion and Courage, Michael Garron Hospital is committed to providing accessible employment practices that are in compliance with the Accessibility for Ontarians with Disabilities Act (AODA) and Ontario Human Rights Code (OHRC). Should you require an accommodation at any stage of the recruitment process, please let us know how we can work with you to meet your needs.
This job posting is a confirmed, active vacancy for which we are currently seeking a qualified candidate.
MGH is committed to leveraging new technologies and working efficiently. As a result, artificial intelligence systems may be used as part of our process to screen, assess, and or select applicants for this position.
The Clinical Documentation Specialist ensures the accuracy, completeness, timeliness, accessibility, confidentiality, and integrity of the health record. The role combines health information management and clinical documentation practices with specialized quality assurance, report distribution, documentation-completeness monitoring, and clinician workflow support. This role involves close collaboration with physicians and residents to offer training for clinical documentation dictation, optimize clinical documentation integrity, and facilitate quality patient care.
EDUCATION
- Diploma or degree in Health Information Management is required
- Medical Transcriptionist Certificate and equivalent experience is preferred
- Certificate in Clinical Documentation Improvement preferred
- Current Canadian Health Information Management Association certification is preferred
- Minimum three years of recent experience in an acute-care environment performing clinical document quality assurance, or related health information management functions
- Proficiency in Electronic Medical Record software, such as Oracle Cerner is preferred
- Experience in Dragon medical Dictation consider as an asset.
- Working knowledge and understanding of transcription and dictation systems
- Experience using eScription platform is considered a strong asset
- Ability to edit and critique transcripts through Quality Assurance required
- Excellent knowledge of Medical Terminology and use of the English language (grammar, spelling, editing)
- Excellent and accurate keyboarding skills (80-100 wpm)
- Experience working in Microsoft Office and Internet Explorer required
- Excelent analytical, attention to detail and problem-solving skills
- Good work and attendance record required.
- Good interprofessional skills and communication skills
- Working with confidential personal health information and the ability to understand and apply key
- Good work and attendance record required.
- All employees of Michael Garron Hospital (MGH), a division of Toronto East Health Network (TEHN) [formerly Toronto EastGeneral Hospital (TEGH)] agree to work within the legislated practices of the Occupational Health and Safety Act of Ontario.
- All employees of MGH are responsible to contribute to a transparent culture of patient and staff safety by adhering to and abiding by patientand staff safety policies and procedures set by MGH.
- All employees are accountable for protecting the psychological health and safety of themselves and their co-workers through adherence to MGH's policies and practices.
Michael Garron Hospital (MGH) champions accessibility, diversity and equal opportunity through the creation of an inclusive and diverse work environment. At Michael Garron Hospital, we strive to be an equitable and inclusive employer. We encourage candidates from Black, First Nations, Métis and Inuit, racialized and LGBTQ2S+ communities, people of colour, women, people with disabilities and individuals who identify with the diverse communities that we serve, to join the MGH team.
Through our values of Compassion, Respect, Integrity, Inclusion and Courage, Michael Garron Hospital is committed to providing accessible employment practices that are in compliance with the Accessibility for Ontarians with Disabilities Act (AODA) and Ontario Human Rights Code (OHRC). Should you require an accommodation at any stage of the recruitment process, please let us know how we can work with you to meet your needs.
This job posting is a confirmed, active vacancy for which we are currently seeking a qualified candidate.
MGH is committed to leveraging new technologies and working efficiently. As a result, artificial intelligence systems may be used as part of our process to screen, assess, and or select applicants for this position.
More about this job
Responsibilities
Ensure health records are accurate, complete, timely, accessible, confidential, and properly maintained through documentation quality assurance, report distribution, and completeness monitoring. Collaborate with physicians and residents to provide dictation training, improve clinical documentation integrity, and support quality patient care.
Requirements
A diploma or degree in Health Information Management and at least three years of recent acute-care experience in clinical document quality assurance or related health information management functions are required. Candidates should have strong medical terminology, English editing, keyboarding, and communication skills; experience with EMR and dictation platforms is preferred or considered an asset, and a Medical Transcriptionist Certificate and clinical documentation or health information management certifications are preferred.
Skills
- Clinical Documentation Quality Assurance
- Health Information Management
- Medical Transcription
- Electronic Medical Records
- Medical Dictation Systems
- Transcript Editing
- Medical Terminology
- English Grammar and Spelling
- Keyboarding
- Microsoft Office
- Analytical Skills
- Attention to Detail
- Problem-Solving
- Communication
- Health Information Privacy
Visa sponsorship
Not detected in the job text
Categories
- Healthcare
- Administrative
Keywords
- Health Information Management
- Clinical Documentation
- Clinical Document Quality Assurance
- Acute Care
- Electronic Medical Record
- Oracle Cerner
- Dragon Medical Dictation
- eScription
- Medical Transcription
- Transcription Systems
- Dictation Systems
- Transcript Editing
- Medical Terminology
- English Grammar
- Keyboarding
- Microsoft Office
- Internet Explorer
- Privacy Legislation
- Personal Health Information
- Quality Patient Care
- Clinical Documentation Integrity
- Canadian Health Information Management Association
- Occupational Health and Safety Act of Ontario
- Accessibility for Ontarians with Disabilities Act
- Ontario Human Rights Code