Medical writer

• Facilitates the improved integrity of medical record documentation.
• Presents opportunities and educates providers on quality clinical documentation and serves as a resource for providers and administrative staff to ensure the clinical documentation within the medical record is accurate and compliant in accordance with internal operating guidelines and regulatory standards (CMS, OIG, ACDIS).
• Performs daily evaluation of medical record documentation to include provider notes, lab results, diagnostic information and treatment plans, and communicates with providers face to face or via query forms to clarify or obtain missing, unclear or conflicting documentation.
• Demonstrates an understanding of complications, co-morbidities, severity of illness, risk or mortality, case mix index, secondary diagnoses, and the impact of procedures on the final Diagnosis Related Group (DRG) and demonstrates the ability to impart this knowledge to providers, to gather and analyze information pertinent to documentation findings and outcomes.

RN Clinical Documentation Specialist

Principal Medical Writer

Clinical Documentation Specialist

Clinical Documentation Specialist

Registered Nurse, Clinical Documentation Specialist – CDIP, CCDS Required