CST Specialist Clinical Documentation Improvement

Work Area: 
CST Prj-DBII Resource-Learning
Base Site: 
CST - 590 W 8th
Regular Full Time
Job Category: 
Health Information Management
Acute Care Hospital


Reporting to the Director, Clinical Informatics, Clinical Systems & Transformation and working closely with the Health Information Management Coding Leadership Team, HIM Customer Service Leader, Medical Directors, Program Directors, physicians, and in collaboration with interprofessional practice, the Specialist, Clinical Documentation Improvement is responsible for leading clinical documentation improvement, researching and analysing technology to leverage for use in practice and enhancement of service delivery, and providing innovative clinical documentation education in order to meet the ongoing needs of complete documentation for continuity of care and clinical data collection. The position develops relevant clinical documentation education materials and provides related training to ensure accurate documentation practices. The position executes a variety of a variety of analyses related to the quality of documentation and ensures ongoing feedback, development and improvement of documentation practices.

In addition, the position works closely with the Coding Leadership Team, Coders, Data Analysts, MIT and external vendors as the primary business application support of the assigned Coding and external vendors as the primary business application support of the assigned Coding computer application(s) within a specific Lower Mainland Health Information Services area, for applications such as Med2020 WinRecs, 3M Codefinder, 3M HDM, Abstracting, and Cerner.


Comprehensive knowledge of health information management. 
Demonstrated knowledge of ICD-10-CA/CCI and national and provincial standards.
Demonstrated knowledge of Case Mix Groups (CMGs), Comprehensive Ambulatory Classification System (CACS), Resource Intensity Weight (RIW) and Expected Length of Stay (ELOS).
Demonstrated knowledge of computer technology and ability to communicate and interact effectively with vendors and other system stakeholders.
Demonstrated knowledge and ability to utilize and troubleshoot computer software applications and report writer tools, such as Crystal Report design, MS SQL Server Management Studio, the MS office suite (Word, Excel, Access, Powerpoint) and MS Sharepoint.
Demonstrated ability to communicate and problem-solve issues related to clinician documentation education and materials.
Demonstrated ability to establish goals and objectives based on client need.
Demonstrated ability to assess individual and group learning needs.
Demonstrated ability to plan, deliver and evaluate educational sessions and programs, and to teach and lead small and large group sessions.
Demonstrated ability to communicate and deal effectively with others both verbally and in writing.
Demonstrated ability to function as an effective team member.
Demonstrated ability to work effectively with others and demonstrate interpersonal skills. 
Demonstrated ability to adjust to new and unexpected events and to deal with and/or guide others in the resolution of conflict issues.
Demonstrated ability to draft policies and procedures, education materials, and curriculum and develop and implement a quality improvement program.
Demonstrated ability to operate related equipment and software applications, including the ability to perform advanced functions in spreadsheet, database, and word-processing software and the ability to use a keyboard and mouse.
Demonstrated interest and progress in professional development (i.e., completion of courses, workshops).
Physical ability to carry out the duties of the position.


Graduation from an accredited Health Information Management Diploma or Bachelor Program.
Five (5) years’ of recent, related experience, including two (2) years’ experience in International Classification of Diseases (ICD-10) coding, and two (2) years’ experience in data quality assurance management or as a systems application coordinator in a data management environment or in data reporting analysis. Experience with NACRS reporting and experience in leadership/supervisory position or education/training position, or an equivalent combination of education, training and experience. Canadian Health Information Management Association (CHIMA) Certified.

Education in computer science/programming and project management would be an asset.


Leads clinical documentation improvement activities, researching and analyzing technology to leverage for use in clinical documentation practice and enhancement of service delivery.

Is responsible for the computer program, undertakes quality assurance initiatives for assigned Computer Software Systems, specific to Coding and provides support for assigned applications such as system testing, changing/updating, setting up, and first-line troubleshooting of systems and related interfaces.

Determines and documents all system issues requiring escalation. Participates in communication of issues related to system functionality.

Liaises between Coding Services and the vendor application specialist and/or IS for business requirements, issues such as dictionary building, interfaces, and integration with other clinical information systems as well as designing reports.

Provides visible, accessible clinical support to the clinicians by acting as an education resource for clinicians related to documentation.

Utilizes the principles of adult education, assesses, plans, develops, implements, conducts and evaluates clinical documentation education and materials for clinicians.

Develops and conducts regular documentation audits to ensure on-going quality and compliance with established documentation guidelines.

Prepares and presents routine and ad hoc reports or statistical information related to clinician documentation to stakeholders.

Performs the duties of a Health Information Management professional with comprehensive knowledge of health information management and strong knowledge of coding and abstracting, and national and provincial standards.

Improves, promotes and enhances documentation competence through ongoing clinician feedback and development of a clinician engagement program (e.g. physician peer review). 

Assesses Coding needs and participates in the design and specification and development of training documentation.

Works collaboratively and coordinates with HIM Customer Service Leader along with Record Management, Registration and Transcription to address documentation issues.

Participates on committees related to clinician documentation and participates in meetings and forums that address professional practice and clinical education issues.

Collaborates with other members of the clinical program teams and with educators across other programs to share information, plan collaboratively, use resources efficiently and improve the quality of documentation and clinician education.

Participates in the development of documentation standards for clinicians by reviewing current literature and research, identifying new theories/trends and making recommendations to ensure standards are current, based on evidence and reflective of “best practices” in documentation.

Reviews documentation policies, procedures and reference materials, and makes recommendations for improvement as requested.

Performs other related duties as required.