Clinical Documentation Trainer

The purpose of this position is to plan, develop and provide training and ongoing support to providers and other clinicians on effective, accurate documentation of patient care. Effective documentation facilitates the capture of all applicable diagnoses to reflect accurate reimbursement, quality of care, coding reflective of the providers intent and full capture of the patient’s severity of illness and risk of mortality. Accurate documentation also impacts hospital quality scores as they relate to mortality, patient safety indicators, healthcare acquired conditions and core measure compliance.

This position is focused on efforts to improve provider clinical documentation to facilitate an accurate clinical picture of the patient, including severity of illness, risk of mortality and resource utilization. The clinician is responsible for collaborating with CDI, coding and provider teams to plan, develop and implement clinical documentation education programs for providers through the analysis of data to ascertain where education is needed. The incumbent will conduct individual and large group educational sessions for providers with a continual feedback loop on improvements and additional areas of opportunity. The CDI Clinical Trainer reviews and analyzes health records to identify relevant diagnoses and procedures for distinct patient encounters. The clinician is then responsible collaborating with providers to educate on the translation of diagnostic phrases utilized by healthcare providers into coded form.

This position is challenged to be aware of the continual changes in Federal and State regulations for prospective payment and keep informed of changes in treatment modes and new procedures.

KNOWLEDGE, SKILLS & ABILITIES:

1. Advanced clinical expertise and extensive knowledge of the disease processes with broad clinical experience in an inpatient setting.

2. A broad knowledge of the disease process, normal/abnormal finding and reasonable course of treatment

3. Strong understanding of the requirements for clinical coding and billing according to rules of Medicare, Medicaid and other commercial payers.

4. Skilled in adult education techniques and the principles of adult learning. Demonstrated competency in the teaching/learning process.

5. Creation of individualized and group training materials specific to the population being trained.

6. Analyze reporting data to uncover documentation trends and opportunities

7. Employ creative approaches to training content delivery, such as 1:1 and group training, case studies, or other methodologies.

8. Exceptional communication and organizational skills with a professional demeanor

9. Strong motivator.

10. Excellent problem solving and analytical skills.

11. Work schedule flexibility required as training and support may be required on weekends and during evening and night shifts.

12. Collaborate with coding and CDI leadership team to assist in determining training needs of the organization as it relates to CDI.

This position does not provide patient care.

The foregoing description is not intended and should not be construed to be an exhaustive list of all responsibilities, skills and efforts or work conditions associated with the job. It is intended to be an accurate reflection of the general nature and level of the job.

Name

Description

Education:

Must have working-level knowledge of the English language, including reading, writing and speaking English. Appropriate education to obtain and maintain state of Nevada Registered Nursing License. BSN preferred.

Experience:

Minimum of 5 years’ experience in the acute care hospital setting working as an RN. 2 to 4 years work related experience in the Clinical Documentation Improvement field.

License(s):

Ability to obtain and maintain a State of Nevada Registered Nurse license.

Certification(s):

CCDS Certification Preferred.

Computer / Typing:

Functional knowledge in the use of Microsoft Office Suite (Word, Excel, PowerPoint and Outlook).

Must possess, or be able to obtain within 90 days, the computers skills necessary to complete online learning requirements for job-specific competencies, access online forms and policies, complete online benefits enrollment, etc.