Lake Regional Health System

Medical writer

• Responsible for performing concurrent reviews of patient records to ensure complete, accurate, and specific clinical documentation.
• Should have a comprehensive understanding of ICD and CPT Coding Guidelines.
• Responsible for clarifying conflicting, incomplete, or imprecise documentation by actively seeking answers and actively educating providers.
• Work to continuously improve clinical documentation to best reflect the care provided and corresponding reimbursement.
• Responsible for improving the overall quality and completeness of clinical documentation.
• Facilitate modifications to clinical documentation through extensive concurrent interaction with physicians, nursing staff, other patient caregivers, and Coding staff to support that appropriate reimbursement, clinical severity of illness, and risk of mortality is captured for the level of service rendered to all patients.
• Supports timely, accurate and complete documentation of clinical information used for measuring and reporting physician and practice outcomes.
• Educates all members of the patient care team on an ongoing basis.

Clinical Documentation Improvement Specialist

• Responsible for performing concurrent reviews of patient records to ensure complete, accurate, and specific clinical documentation.
• Should have a comprehensive understanding of Coding Guidelines and are responsible for clarifying conflicting, incomplete, or imprecise documentation by actively seeking answers and actively educating providers.
• Work to continuously improve clinical documentation to best reflect the care provided and corresponding reimbursement.
• Responsible for improving the overall quality and completeness of clinical documentation.
• Facilitate modifications to clinical documentation through extensive concurrent interaction with physicians, nursing staff, other patient caregivers, and Physician Practice Coding staff to support that appropriate reimbursement, clinical severity of illness, and risk of mortality is captured for the level of service rendered to all patients.
• Supports timely, accurate and complete documentation of clinical information used for measuring and reporting physician and practice outcomes.
• Educates all members of the patient care team on an ongoing basis.

Clinical Documentation Improvement Specialist

Outpatient Clinical Documentation Improvement Specialist