Epic Implementation Clinical Documentation Specialist in Linton, Indiana at Greene County General Hospital

The Epic Implementation/Clinical Documentation Specialist serves as the hospital’s subject matter expert for clinical documentation integrity, Epic electronic health record (EHR) implementation, EHR optimization, and clinical workflow design. This role bridges clinical operations, quality, regulatory compliance, health information management, and information technology to ensure accurate, complete, compliant, and efficient documentation within the EHR. The Specialist provides on-site clinical leadership for Epic implementation, workflow validation, user readiness, go-live support, and post-implementation optimization. This is an on-site position.

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.