Job Summary
Manages and maintains clinical quality documentation for healthcare organizations. Ensures compliance with regulatory requirements and standards by developing and implementing documentation processes and procedures. Reviews and analyzes documentation for accuracy, completeness, and adherence to guidelines. Collaborates with cross-functional teams to identify areas for improvement and implement corrective actions. Provides training and support to staff on documentation practices and quality improvement initiatives. Monitors and reports on key performance indicators related to clinical documentation and quality outcomes.
Roles and Responsibilities
• Conceptualizes the development of all clinical excellence enterprises.
• Participates and identifies strategies for improving professional development activities, clinical system practices, and effective system use by users for quality improvement.
• Provides clinical content expertise and knowledge of care provider systems to create solutions that will impact quality across the care continuum.
• Creates and assists in the development of accurate documentation in MatrixCare.
• Troubleshoots and assists in creating an action plan for quality improvement.
• Establishes the strategic direction to incorporate division based multi-disciplinary teams that are focused on reducing variations and improving clinical performance.
• Assists in readiness of the state surveys.
• Utilizes trends, quality data and analysis to identify and design a plan to implement performance improvement initiatives in quality and safety indicators.
• Provides education related to quality measures, processes, and procedures.
• Designs and conducts analysis that quantifies the impact of policy and/or market changes.
• Directs automated reporting to provide timely information, allowing decisions to be made in a real-time environment.
• Reviews medical record documentation for newly admitted residents to ensure all documentation is in place to support the primary medical diagnosis.
• Uses critical thinking skills to know when to request and communicate on missing documentation essential to supporting the resident’s SNF stay.
• Reviews all infection, fall and wound events and tracks, analyzes trends, and advises management on areas of improvement.
• Develops tools to optimize the efficiency of clinical quality and reporting clinical quality, strategies, and analytical needs.
• Directs and provides leadership of the clinical data systems.
• Ensures that systems are kept up to date; eliminating reporting that is no longer relevant.
• Collaborates with department heads, divisional support, and campus personnel to achieve goals and objectives.
• Completes external audit requests and uploads them timely.
• Other duties as assigned.
Qualifications
Education: High School / GED
Experience: 1-3 years
Licenses and Certifications
None Required
