Important Notices & Amendments

As an employer of choice, Niagara Region offers competitive salaries and benefits, a defined benefit pension plan, a corporate wellness centre, access to the Employee and Family Assistance Program (EFAP), mentorship and training programs, employee recognition programs, and more. In addition, the Region recognizes the value of having flexible work arrangements to support better work-life balance for our employees. Hybrid work arrangements may vary from one employee to another and may also differ in the number of remote workdays. These opportunities remain subject to the alignment of operational needs, business requirements, and customer service expectations.

Job Description

Job Summary

Reporting to the Supervisor Clinical Documentation & Informatics, the Clinical Documentation & Informatics Lead is responsible for maintaining the homes clinical documentation system, and electronic Resident Assessment Instrument (RAI) system, ensuring that the systems are managed in a manner that is compliant with Provincial and Regional Standards, related legislation and polices.

Education

• Current regulated or licensed health care practitioner (e.g. RPN, RN, BSW, MSW, Dietitian).
• Recognized RAI credentials or equivalent.
• Adult Education Certificate an asset.

Knowledge

• At least 3 years of clinical experience within a Long-Term Care Home environment.
• At least 1 year of project management experience.
• Excellent knowledge and experience with adult education strategies/facilitation.
• Excellent knowledge and experience with computerized clinical documentation systems and RAI is required.
• Certificate in Adult Education or Training is preferred.
• Knowledge of interdisciplinary team members, Ministry documentation standards and home policies on assessment and care planning is preferred.
• Proficiency with Point Click Care.
• Knowledge and proficiency of computer software applications, including word processing, spreadsheets, preferably Microsoft Applications.
• Demonstrated Leadership and Communication skills preferred.
• Knowledge and understanding of The Personal Information Protection and Electronic Document Act (PIPEDA).

Responsibilities

Maintains the home’s clinical documentation system, and electronic Resident Assessment Instrument (RAI) system. (15% of time)

• Serves as the subject matter expert on RAI and clinical documentation, providing direction, guidance, and coaching to staff within the home.
• Conducts audits of the Point Click Care EMR system to ensure accuracy and compliance.
• Acts as the systems administrator for clinical documentation systems, managing in-home system functionality, assigning, and modifying user access, and overseeing system upgrades with support from Supervisor of Clinical Documentation and Informatics.
• Identifies issues with systems or processes and collaborates with relevant teams to develop effective solutions with support from Supervisor of Clinical Documentation and Informatics.
• Ensures compliance with RAI and clinical documentation procedures in accordance with home policies, MOHLTC regulations, College Standards, and interRAI requirements.
• Works closely with vendors to ensure ongoing support and optimization of clinical documentation systems in collaboration and support from Supervisor of Clinical Documentation and Informatics.

Ensures the timely completion of MDS assessments, resident assessment protocols, and care plans. (40% of time)

• Develops and maintains the resident assessment schedule, ensuring it is completed on time and accessible to staff.
• Audits RAI and clinical documentation records to verify accuracy and ensure data integrity.
• Safeguards the confidentiality of staff and resident information, ensuring compliance with privacy standards.
• Leads the development and improvement of RAI and clinical documentation processes within the home, focusing on data accuracy, efficient data collection, timely assessment completion, and effective data utilization.
• Ensures the accurate completion or delegation of all MDS assessments, including those for Significant Change in Status.

Provides RAI education and computer application training to all users, observe and assist in the application of knowledge, and evaluate outcomes. (20% of time)

• Trains staff on the technical and professional skills needed to effectively use the program and provides ongoing assistance in applying these skills.
• Oversees the Electronic Medical Record (EMR) processes within the home.
• Serves as the primary point of contact for Point Click Care and all documentation-related processes in the home.
• Collaborates with the leadership team to support all operational processes.
• Provides regular communication and support to staff regarding updates or changes to EMR software, processes, or clinical assessments.
• Supports and facilitates compliance with clinical documentation and care planning procedures, ensuring adherence to applicable college standards (e.g., College of Nurses).
• Facilitates training for new hires and conducts annual refresher courses on assessments, processes, and navigation of the Point Click Care EMR.
• Collaborates with the interdisciplinary team to develop and implement therapeutic care plans, focusing on goals, interventions, clinical assessments, and documentation.
• Provides on-the-spot support to staff with clinical assessments, documentation, and care planning.

Analyzes management information and generates regular reports from the MDS-RAI, and other relevant systems, to be used in clinical and management decision-making. (20% of time)

• Ensures that data submission requirements and processes are established and functioning effectively.
• Verifies that monthly electronic submissions are accurate and correctly transmitted through the EMR to the appropriate repository for acceptance.

Provides input on staff performance to accountable managers for staff appraisal purposes, participating in transfer, promotion, demotion, and discipline decisions. (5% of time)

Special Requirements

• In accordance with the Corporate Criminal Record Check Policy, the position requires the incumbent to undergo a Criminal Records Check, including a vulnerable sector search, and submit a Canadian Police Clearance Certificate.
• Licensed health care practitioners must undertake continuing education to maintain their license.
• Regional staff strive to enable the strategic priorities of council and the organization through the completion of their work. Staff carry out their work by demonstrating the corporate values.

About Us

Serving a diverse urban and rural population of more than 475,000, Niagara Region is focused on building a strong and prosperous Niagara. Working collaboratively with 12 local area municipalities and numerous community partners, the Region delivers a range of high-quality programs and services to support and advance the well-being of individuals, families and communities within its boundaries. Nestled between the great lakes of Erie and Ontario, the Niagara peninsula features some of Canada’s most fertile agricultural land, the majesty of Niagara Falls and communities that are rich in both history and recreational and cultural opportunities. Niagara boasts dynamic modern cities, Canada’s most developed wine industry, a temperate climate, extraordinary theatre, and some of Ontario’s most breathtaking countryside. An international destination with easy access to its binational U.S. neighbour New York State, Niagara attracts over 14 million visitors annually, as well as a steady stream of new residents and businesses.

At Niagara Region, we value diversity - in background and experience. We are proud to be an equal opportunity employer. We aspire to hire and grow a workforce reflective of the diverse community we serve. By doing so, we can deliver better programs and services across Niagara.

We welcome all applicants! For more information about diversity, equity, and inclusion at Niagara Region, Diversity, Equity and Inclusion - Niagara Region, Ontarioor email related questions to diversity@niagararegion.ca. To send input on reducing barriers in the current hiring process, please email myhr@niagararegion.ca

For the Region's full employee equity statement, Working at Niagara Region - Niagara Region, Ontario.

While specific qualifications are important for certain roles, we invite individuals from diverse backgrounds to apply. Our recruiters will evaluate your suitability for the role.

Closing Statement

Uncover the wonder of the Niagara Region and join a team dedicated to meeting tomorrow’s challenges TODAY!

Let us know why you would be an excellent team member by submitting your online application.

We thank all candidates for their interest however, only those candidates selected for an interview will be contacted.

We confirm that we do not use AI in screening of applicants, and this position is an existing vacancy.

If you require an accommodation for the application process in accordance with the Ontario Human Rights Code and the Accessibility for Ontarians with Disabilities Act, the alternate formats for contacting us are as follows:

• Email: myhr@niagararegion.ca
• Phone: 905-980-6000 or 1-800-263-7215
• Bell Relay: 1-800-855-0511
• In-person: Sir Isaac Brock Way, Thorold, ON L2V 4T7 – Human Resources Department