Oneida Health

Medical writer

• Conduct thorough reviews of patient medical records to identify opportunities for enhanced documentation accuracy.
• Collaborate with physicians, nurses, and other healthcare professionals to obtain clarification and additional information supporting precise coding.
• Educate and train clinical staff on best practices for documentation improvement and coding guidelines.
• Analyze coding and documentation trends to identify areas for process improvement and implement strategies to address deficiencies.
• Assist in developing and implementing policies and procedures related to clinical documentation improvement.
• Stay updated on changes in coding guidelines, regulations, and Meditech updates to ensure compliance and adherence to best practices.

Clinical Documentation Improvement Specialist