This role bridges clinical operations, quality, regulatory compliance, health information management, and information technology to ensure accurate, complete, compliant, and efficient documentation ...
This role bridges clinical operations, quality, regulatory compliance, health information management, and information technology to ensure accurate, complete, compliant, and efficient documentation ...
This role bridges clinical operations, quality, regulatory compliance, health information management, and information technology to ensure accurate, complete, compliant, and efficient documentation ...
This role bridges clinical operations, quality, regulatory compliance, health information management, and information technology to ensure accurate, complete, compliant, and efficient documentation ...
CLINICAL DOCUMENT SPECIALIST
Merrillville, IN ยท On-site
$34.25 - $46/hr
Minimum 3 years' experience in Clinical documentation Improvement (Preferred), hospital inpatient quality chart review or Case Management * RHIA - Registered Health Info Administrator * RHIT ...
CLINICAL DOCUMENT SPECIALIST
Merrillville, IN ยท On-site
$34.25 - $46/hr
Minimum 3 years' experience in Clinical documentation Improvement (Preferred), hospital inpatient quality chart review or Case Management * RHIA - Registered Health Info Administrator * RHIT ...
CLINICAL DOCUMENT SPECIALIST
Merrillville, IN ยท On-site
$34.25 - $46/hr
Minimum 3 years' experience in Clinical documentation Improvement (Preferred), hospital inpatient quality chart review or Case Management * RHIA - Registered Health Info Administrator * RHIT ...
CLINICAL DOCUMENT SPECIALIST
Merrillville, IN ยท On-site
$34.25 - $46/hr
Minimum 3 years' experience in Clinical documentation Improvement (Preferred), hospital inpatient quality chart review or Case Management * RHIA - Registered Health Info Administrator * RHIT ...
CLINICAL DOCUMENT SPECIALIST
$34.25 - $46/hr
Minimum 3 years' experience in Clinical documentation Improvement (Preferred), hospital inpatient quality chart review or Case Management * RHIA - Registered Health Info Administrator * RHIT ...
CLINICAL DOCUMENT SPECIALIST
$34.25 - $46/hr
Minimum 3 years' experience in Clinical documentation Improvement (Preferred), hospital inpatient quality chart review or Case Management * RHIA - Registered Health Info Administrator * RHIT ...
The Epic Acute Clinical Documentation Analyst supports the implementation, optimization, and ... This role partners with clinical teams, case managers, and IT teams to ensure the modules meet ...
The Epic Acute Clinical Documentation Analyst supports the implementation, optimization, and ... This role partners with clinical teams, case managers, and IT teams to ensure the modules meet ...
The Epic Acute Clinical Documentation Analyst supports the implementation, optimization, and ... This role partners with clinical teams, case managers, and IT teams to ensure the modules meet ...
The Epic Acute Clinical Documentation Analyst supports the implementation, optimization, and ... This role partners with clinical teams, case managers, and IT teams to ensure the modules meet ...
The Epic Acute Clinical Documentation Analyst supports the implementation, optimization, and ... This role partners with clinical teams, case managers, and IT teams to ensure the modules meet ...
The Epic Acute Clinical Documentation Analyst supports the implementation, optimization, and ... This role partners with clinical teams, case managers, and IT teams to ensure the modules meet ...
Diagnosis Related Group Clinical Validation Auditor-RN (CDI, MS-DRG, AP-DRG and APR-DRG)
Indianapolis, IN ยท On-site
$82K - $155K/yr
... established by audit management. * Identifies potential documentation and coding errors by ... Broad knowledge of clinical documentation improvement guidelines, medical claims billing and ...
Diagnosis Related Group Clinical Validation Auditor-RN (CDI, MS-DRG, AP-DRG and APR-DRG)
Indianapolis, IN ยท On-site
$82K - $155K/yr
... established by audit management. * Identifies potential documentation and coding errors by ... Broad knowledge of clinical documentation improvement guidelines, medical claims billing and ...
Diagnosis Related Group Clinical Validation Auditor-RN (CDI, MS-DRG, AP-DRG and APR-DRG)
Indianapolis, IN ยท On-site
$82K - $155K/yr
... established by audit management. * Identifies potential documentation and coding errors by ... Broad knowledge of clinical documentation improvement guidelines, medical claims billing and ...
Diagnosis Related Group Clinical Validation Auditor-RN (CDI, MS-DRG, AP-DRG and APR-DRG)
Indianapolis, IN ยท On-site
$82K - $155K/yr
... established by audit management. * Identifies potential documentation and coding errors by ... Broad knowledge of clinical documentation improvement guidelines, medical claims billing and ...
Documentation Specialist II
Mishawaka, IN ยท On-site
The Documentation Specialist II reports activities monthly to the Clinical Documentation ... Interacts collaboratively with medical staff, nursing staff, coding staff, case managers, and other ...
Documentation Specialist II
Mishawaka, IN ยท On-site
The Documentation Specialist II reports activities monthly to the Clinical Documentation ... Interacts collaboratively with medical staff, nursing staff, coding staff, case managers, and other ...
The Documentation Specialist II reports activities monthly to the Clinical Documentation ... Interacts collaboratively with medical staff, nursing staff, coding staff, case managers, and other ...
The Documentation Specialist II reports activities monthly to the Clinical Documentation ... Interacts collaboratively with medical staff, nursing staff, coding staff, case managers, and other ...
Clinical Director
Indianapolis, IN ยท On-site
$90K - $100K/yr
Documents client sessions and manages discharges as needed Direct Clinical Services * Provides therapy and maintains a clinical caseload * Ensures ethical, culturally sensitive and clinically ...
Quick apply
Clinical Director
Indianapolis, IN ยท On-site
$90K - $100K/yr
Documents client sessions and manages discharges as needed Direct Clinical Services * Provides therapy and maintains a clinical caseload * Ensures ethical, culturally sensitive and clinically ...
DRG Clinical Validation Lead
Indianapolis, IN ยท On-site
$89K - $161K/yr
May also manage appeals for services denied. How you will make an impact: * Conducts pre ... Broad knowledge of clinical documentation improvement guidelines, medical claims billing and ...
DRG Clinical Validation Lead
Indianapolis, IN ยท On-site
$89K - $161K/yr
May also manage appeals for services denied. How you will make an impact: * Conducts pre ... Broad knowledge of clinical documentation improvement guidelines, medical claims billing and ...
DRG Clinical Validation Lead
Indianapolis, IN ยท On-site
$89K - $161K/yr
May also manage appeals for services denied. How you will make an impact: * Conducts pre ... Broad knowledge of clinical documentation improvement guidelines, medical claims billing and ...
DRG Clinical Validation Lead
Indianapolis, IN ยท On-site
$89K - $161K/yr
May also manage appeals for services denied. How you will make an impact: * Conducts pre ... Broad knowledge of clinical documentation improvement guidelines, medical claims billing and ...
RN Clinical Manager
Fort Wayne, IN ยท On-site
Registered Nurse Clinical Manager - Home Health Exciting opportunity to be apart of a new BAYADA ... Review and monitor clinical documentation within Home Care Home Base * Ensure compliance with ...
RN Clinical Manager
Fort Wayne, IN ยท On-site
Registered Nurse Clinical Manager - Home Health Exciting opportunity to be apart of a new BAYADA ... Review and monitor clinical documentation within Home Care Home Base * Ensure compliance with ...
Document Specialist - 1799235
$24 - $25/hr
... clinical trial documents, and other essential records. Responsibilities: * Document Management: Ensure the accurate and timely creation, revision, and maintenance of documents, adhering to ...
Quick apply
Document Specialist - 1799235
$24 - $25/hr
... clinical trial documents, and other essential records. Responsibilities: * Document Management: Ensure the accurate and timely creation, revision, and maintenance of documents, adhering to ...
DRG Clinical Validation Lead
Indianapolis, IN ยท On-site
$89K - $161K/yr
May also manage appeals for services denied. How you will make an impact: * Conducts pre ... Broad knowledge of clinical documentation improvement guidelines, medical claims billing and ...
DRG Clinical Validation Lead
Indianapolis, IN ยท On-site
$89K - $161K/yr
May also manage appeals for services denied. How you will make an impact: * Conducts pre ... Broad knowledge of clinical documentation improvement guidelines, medical claims billing and ...
RN Clinical Manager
Fort Wayne, IN ยท On-site
Registered Nurse Clinical Manager - Home Health Exciting opportunity to be apart of a new BAYADA ... Review and monitor clinical documentation within Home Care Home Base * Ensure compliance with ...
Quick apply
RN Clinical Manager
Fort Wayne, IN ยท On-site
Registered Nurse Clinical Manager - Home Health Exciting opportunity to be apart of a new BAYADA ... Review and monitor clinical documentation within Home Care Home Base * Ensure compliance with ...
Licensed Clinical Social Worker (LCSW)
Indianapolis, IN ยท Remote
$115K - $120K/yr
... manage challenges that affect daily life, emotional health, and long-term stability. This is a ... Maintain timely and accurate clinical documentation * Monitor client progress and adjust care ...
Licensed Clinical Social Worker (LCSW)
Indianapolis, IN ยท Remote
$115K - $120K/yr
... manage challenges that affect daily life, emotional health, and long-term stability. This is a ... Maintain timely and accurate clinical documentation * Monitor client progress and adjust care ...
Clinical Documentation Manager information
What is a Clinical Documentation Manager job?
A Clinical Documentation Manager oversees the accuracy, completeness, and consistency of medical records to ensure compliance with healthcare regulations and improve patient care. They collaborate with physicians, coders, and other healthcare professionals to enhance documentation quality for proper reimbursement and compliance. Their responsibilities include training staff, conducting audits, and implementing documentation improvement initiatives. This role plays a critical part in supporting accurate coding, billing, and overall healthcare data integrity.
What are the main challenges a Clinical Documentation Manager might face in their role?
Clinical Documentation Managers often face the challenge of ensuring consistent, accurate, and timely documentation across a variety of clinical teams, while staying compliant with evolving regulations and healthcare standards. Balancing the needs of clinicians with organizational documentation requirements and providing ongoing education to staff can be demanding. Additionally, managing a team that may work across different departments requires strong collaboration and adaptability. Overcoming these challenges is critical to maintaining data integrity, supporting quality patient care, and facilitating accurate reimbursement processes.
What are the key skills and qualifications needed to thrive in the Clinical Documentation Manager position, and why are they important?
To thrive as a Clinical Documentation Manager, you need strong knowledge of medical terminology, healthcare regulations, and clinical documentation standards, often supported by a degree in health information management, nursing, or a related field. Expertise with EHR systems, coding software (such as ICD-10 and CPT), and certifications like Certified Clinical Documentation Specialist (CCDS) are highly valued. Outstanding communication, attention to detail, leadership, and training abilities set top candidates apart. These competencies ensure accuracy, regulatory compliance, and improved clinical outcomes through high-quality documentation practices.

Epic Implementation Clinical Documentation Specialist
Linton, IN โข On-site
Full-time
Posted 10 days ago
Job description
Essential Duties and Responsibilities:
- Conduct concurrent and retrospective documentation review to ensure completeness, regulatory compliance, and accurate reflection of patient severity and services rendered.
- Communicate documentation clarification opportunities to providers and collaborate with HIM on coding and DRG alignment.
- Monitor provider documentation compliance, including unsigned orders and required regulatory elements.
- Educate clinical staff on documentation standards, regulatory updates, and EHR-related workflow changes.
- Serve as the primary clinical lead for Epic EHR implementation, clinical workflow design, validation, optimization, and ongoing support.
- Translate clinical workflows and operational needs into Epic build requests, workflow specifications, testing scenarios, and training needs in collaboration with IT, operational leaders, and vendor partners.
- Lead or support workflow mapping, readiness assessments, user acceptance testing, integrated testing, issue tracking, go-live preparation, go-live support, and post-live optimization activities.
- Collaborate with clinical leaders, providers, super users, and frontline staff to identify workflow risks, adoption barriers, documentation gaps, and patient safety concerns related to Epic implementation and use.
- Develop, test, validate, and maintain clinical documentation tools, forms, order sets, templates, smart phrases, reports, and other EHR documentation structures as assigned.
- Troubleshoot system issues, prioritize clinical risks, coordinate resolution with IT and vendor partners, and open or manage support tickets as needed.
- Support user access, security role review, clinical system configurations, and workflow-specific permissions in collaboration with IT and organizational leadership.
- Provide onboarding, coaching, just-in-time education, and ongoing training for clinical users, including providers, nursing, ancillary departments, and other clinical staff.
- Support patient portal functionality, interoperability initiatives, provider mapping, electronic data exchange, and communication with external entities or vendors.
- Participate in regulatory readiness, quality improvement, compliance, and patient safety initiatives related to clinical documentation and EHR workflows.
- Serve as a liaison between clinical departments, quality, HIM, IT, and vender partners to ensure alignment of documentation and workflow practices.
- Support a culture of safety through proactive monitoring of documentation and workflow risks.
- Support CareWeb access and troubleshoot user issues.
- Build and maintain ad hoc report templates as assigned.
- Ensures patient care environments and practices support exemplary, safe, and high-quality care of patients and families.
- Ensures that workplace environments are safe and that strategies are in place to prevent physical and psychological harm.
- Demonstrates clear ownership of workplace and patient safety.
- Reports mistakes, near misses, adverse events and quality and safety concerns.
- Develops and implements safety and quality plans that support exemplary workplace and care practices, while also supporting a culture of safety.
- Other duties as may be assigned.
Job Requirements
Education: Associate or Bachelor's degree in Nursing, Healthcare Administration, Health Information Management, Clinical Informatics, or related field; or equivalent combination of education and experience
Experience: Minimum three (3) years of acute care clinical experience required. Experience in clinical documentation improvement, quality management, informatics, utilization review, coding, EHR implementation, or clinical workflow optimization preferred. Experience with Epic or hospital-based EHR systems strongly preferred.
- Advanced proficiency in EHR systems, clinical documentation workflows, and reporting tools.
- Ability to support on-site implementation activities, including workflow review, training, go-live readiness, and direct clinical user support.
- Strong analytical, problem-solving, and communication skills.
- Ability to balance regulatory compliance, reimbursement integrity, workflow efficiency, and patient safety.
- Availability to provide on-site support during implementation, go-live, post-live stabilization, and other operational needs as assigned.
Work Environment: This position is an on-site role located at Greene County General Hospital or assigned hospital-owned locations. The position is not remote and requires in-person presence to support clinical workflows, staff education, implementation activities, go-live support, troubleshooting, and operational needs.
Physical Requirements: Frequent sitting, standing, and walking. Ability to lift up to 25 pounds unassisted. Adequate vision and hearing for effective communication and computer-based work.
About Greene County General Hospital
Sourced by ZipRecruiter
Industry
Health care and social assistance
Company size
201 - 500 Employees
Headquarters location
Linton, IN, US
Year founded
1912