Job Posting #19054

Clinical Doc & Info Lead

Closing Date:Wed., Sep. 27, 2017
Department:Community Services
Location:Northland Pointe
Type:Regular Full-Time
Union:Non Union
Salary:$65,790 - $77,400
Work Hours:35 hrs / week

About Niagara Region

Serving a diverse urban and rural population of more than 430,000, 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.


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.


  • Recognized RAI credentials or equivalent.


  • At least 3 years of clinical experience within a Long-Term Care Home environment.
  • At least 1 year of project management experience.
  • Current regulated or licensed health care practitioner (e.g. RPN, RN, BSW, MSW, Dietitian).
  • 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 preferred.
  • Knowledge of interdisciplinary team members, Ministry documentation standards and home policies on assessment and care planning preferred.


Maintains the home’s clinical documentation system, and electronic Resident Assessment Instrument (RAI) system.
  • Acts as the subject matter expert in the areas of RAI and clinical documentation for staff in the home, providing direction and guidance.
  • Acts as systems administrator in the home for clinical documentation systems, maintaining and evaluating in-home systems, assigning and altering user rights, and ensuring system upgrades.
  • Assesses issues with systems or processes and collaboratively develops solutions.
  • Ensures compliance with RAI and clinical documentation processes in relation to home policies, MOHLTC regulations, College Standards and inter-RAI requirements.
  • Liaises with vendors to support clinical documentation systems.

Ensures the timely completion of MDS assessments, resident assessment protocols, and care plans.
  • Ensures that the resident assessment schedule is developed, completed and accessible to staff.
  • Audits RAI and clinical documentation records for accuracy and data integrity.
  • Ensures that confidentiality of staff and resident information is appropriately maintained.
  • Leads RAI and clinical documentation process developments and improvements in the home, to ensure data accuracy, efficient data collection, assessment completion, and data utilization.

Provides RAI education and computer application training to all users, observe and assist in the application of knowledge, and evaluate outcomes
  • Instructs staff on technical and professional skills required to utilize the program and assist staff in the application of these skills.
  • Provides one-on-one support for staff struggling to document resident status and care activities.

Analyzes management information and generates regular reports from the MDS-RAI, and other relevant systems, to be used in clinical and management decision-making.
  • Ensures that data submission requirements and processes are in place and operating effectively.
  • Ensures that monthly electronic submissions are accurate, and properly sent through to the MOHLTC.

Provides input on staff performance to accountable managers for staff appraisal purposes, participating in transfer, promotion, demotion and discipline decisions.

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 of service, honesty, choice, partnership and respect.

Shift Information

Currently scheduled 35 hours, and may be required to work days, evenings and nights, including weekends.

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.

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