Medical writer

• Completes secondary reviews of targeted patient populations to identify missed opportunities and accurate selection of principal diagnosis.
• Acts as a liaison between the Coding Department and the Clinical Documentation Specialist to reconcile discrepancies in DRG assignment.
• Communicates findings of secondary reviews to respective Clinical Documentation Improvement Specialists and Coding staff for follow up.
• Documents and tracks secondary review data.
• Shares this information with staff at monthly DCI meetings.
• Completes medical record review using an organized approach to survey admit notes, past medical history, home meds, physician/provider documentation, treatments, orders, ancillary department notes, laboratory data and other pertinent components of the clinical record.
• Analyzes and interprets clinical data to identify gaps, trends, inconsistencies and/or opportunities for improvement in the clinical documentation.
• Regularly interacts with/educates physicians to enhance understanding of the CDI program and to ensure the medical record can be coded accurately in order to reflect patient severity of illness and risk of mortality.
• Collaborates with other clinical disciplines and members of the coding department to ensure high quality clinical documentation and efficient, timely coding of the medical record.
• Collaborates with Coding Department when discrepancies in the medical record are identified and reviews medical record to provide clinical feedback for accurate coding.
• Develops collaborative relationships and promotes teamwork with co-workers and other departments.
• Organizes and performs work responsibilities effectively and efficiently.
• Maintains strict patient confidentiality, adhering to HIPPA guidelines.

RN Clinical Documentation Specialist

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Certifications

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