01Key Responsibilities
Documentation Review: Perform regular audits of clinical documentation in the ED to
identify areas for improvement, ensuring accuracy and completeness of report.
Education and Training: Provide ongoing education and training to ED staff on best
practices for clinical documentation, including coding guidelines and regulatory
requirements.
Collaboration: Work closely with Coders/QA staff/Leadership/Clients, ED physicians
and clinical staff to clarify documentation issues and promote accurate coding and
reporting.
Data Analysis: Analyze documentation trends and outcomes to identify opportunities for
improvement in clinical practices and documentation accuracy.
Compliance Monitoring: Ensure adherence to CMS guidelines and other regulatory
requirements related to clinical documentation.
Feedback and Reporting: Develop and present reports on documentation improvement
initiatives and outcomes to immediate supervisor, stakeholders and Senior leadership.
Quality Improvement: Participate in quality improvement initiatives aimed at enhancing
patient care and safety in the ED.
Career development: Stay current with developments in clinical documentation
and coding standards through continuing education and professional organizations.
Qualifications:
Education: Masters/bachelor s degree in any life science stream Medicine,
Physiotherapy, Occupational Therapy, Physician Assistant, Nursing, Pharmacy,
Biomedical, Biochemistry, Microbiology, health information management, or related field.
Experience: Minimum of 4-5 years of clinical experience in an emergency department .
