Clinical Trainer

About the role

The IT Clinic Trainer will work hand in hand with physicians, providers and clinicians and will provide on-site support for technical issues, participates in interdisciplinary rounding, and assists with documentation optimization. This position will be responsible for CDI education for staff and physicians.

Responsibilities

• Reviews outstanding core measure items and related documentation.
• Reviews Certified Data Management Professional (CDMP) and coding queries.
• Addresses inappropriate and/or inadequate documentation practices with clinician.
• Offers assistance with documentation optimization; facilitates use of available system resources.
• Records process activities to reflect any changes in status, procedures/treatments, query activity, and physician activities.
• Actively participates in multidisciplinary rounds.
• Responsible for the education of staff and physicians in the CDI Program process.
• Identifies educational needs and provides training.
• Educates all internal customers on clinical documentation opportunities, coding, and reimbursement issues, as well as performance improvement methodologies, system navigation.
• Participates in the monitoring of quality indicators, as requested.
• Facilitates improvement in the overall quality, completeness, and accuracy of medical record documentation through interaction with physicians, nursing staff, medical record coders, and IT.
• Calls attention to potential changes in principle diagnosis and/or diagnosis that reflect complications, comorbidities, and severity that should be included in the patient's medical record.
• Reviews HIM and Quality audits for documentation/education needs.
• Remains current on workflow changes in Epic.
• Coordinates with IT build teams for needs of clinicians.
• Works with providers to create consistency in documentation practices.
• Participates in training to remain proficient in Epic modules and workflows.
• Collaborates with the appropriate departments or committees for resolution of identified concerns.
• Provides feedback to physicians, departments, and committees as appropriate.
• Supports documentation requirements for JCAHO and state requirements.
• Reduces risk that may exist when clinical documentation is incomplete or unclear.
• Prepares reports on a weekly, quarterly, and/or annual basis as required/requested by manager.
• Ensures compliance with all federal and state regulations and facilitates improvement in documentation through concurrent interaction with physicians, medical record coders, and other healthcare team members.

Qualifications

• High School Diploma or equivalent.
• One of the following licenses as required by state board where services will be provided: MD: Respiratory Care Practitioner through the Maryland Board of Physicians, Current Registered Nurse license issued by the state in which services will be provided or current multi-state Registered Nurse license through the enhanced Nurse Licensure Compact (eNLC), Current Licensed Practical Nurse license issued by the state in which services will be provided or current multi-state Licensed Practical Nurse license through the enhanced Nurse Licensure Compact (eNLC).
• Valid driver’s license.
• Current Basic Life Support (BLS) Certification.

Preferred Qualifications

• Five (5) years of Clinical experience in a hospital setting with a working knowledge of Epic.

Physical Requirements

• Ability to use computer keyboard, monitor, and mouse.
• Ability to communicate verbally, in writing, and electronically with healthcare personnel.

Working Environment

• May be exposed to communicable diseases.

Skills and Abilities

• Functional knowledge of Electronic Medical Record (EMR).
• Critical thinking skills.