Medical writer

• Demonstrates an understanding of complications, co-morbidities, severity of illness, risk of mortality, case mix, secondary diagnoses, impact of procedures on DRG and is able to impart this knowledge to physicians and other health team members.
• Demonstrates and utilizes the guidelines of care and practice via the nursing process and in accordance with Arizona State Board of Nursing Laws and Regulations being able to perform at a fully competent level.
• Maintains a review rate of 80% on assigned cases and query rate of 15% on assigned cases, or as determined by clinical performance need. Performs audits of documentation to ensure consistency and that standards are met.
• Communicates with physicians face-to-face or through clinical documentation inquiry forms to clarify information, obtain needed documentation, present opportunities and educate for appropriate MS-DRG based on severity of illness.
• Confers with HIM coders to ensure appropriate MS-DRG assignment and completeness of supporting documentation.
• Confers with Physician Advisor as needed.
• Conducts concurrent and retrospective review of each assigned patient in the time frame and frequency as required.
• Identifies and records the most appropriate principal diagnosis, secondary diagnosis, complications/co-morbidities and procedures to reflect the severity of illness and risk of mortality.
• Identifies opportunities for improvement in documentation processes.
• Maintains accurate data in the tracking database to identify trends and issues, developing action plans to achieve team goals.
• Responsible for reporting any safety-related incident in a timely fashion through the Midas/RDE tool; attends all safety-related training programs; performs work in a safe manner; monitors work environment for possible safety issues and ensures others are also performing work in a safe manner.
• Stays current and complies with state and federal regulations/statutes and company policies that impact the employee's area of responsibility.
• If required for the position, ensures all certifications and/or licenses are up-to-date and valid prior to expiration dates.
• Completes all company mandatory modules and required job-specific training in the specified time frame.

RN Clinical Documentation Informaticist

Clinical Documentation Integrity Specialist – 2nd Level Reviewer

Principal Medical Writer

Clinical Documentation Specialist

RN Clinical Documentation Specialist

Clinical Documentation Specialist