Medical writer

• Applies clinical expertise and knowledge of health care workflows in order to educate and train CDI Specialists in the essential duties of their role to improve the overall accuracy and comprehensiveness of medical record documentation, with focus on ensuring accurate reporting of quality outcomes
• Educates CDI Specialists on the rules/regulations associated with coding and clinical documentation integrity.
• Trains newly hired CDI Specialists and provides ongoing coaching and education specific to daily CDI Specialist job functions.
• Ensures the work output of the Clinical Documentation Integrity staff is accurate and compliant.
• Collaborates with CDI leadership and Coding team to identify training opportunities and assist with education of CDI and Coding staff with regard to clinical documentation integrity and/or clinical and coding scenarios as needed.
• Performs post-discharge, final coded, pre-bill reviews of targeted records identified for second-level review for opportunity to accurately capture patient acuity, severity of illness, risk of mortality, and DRG assignment in compliance with industry rules and regulations.
• Documents SLR findings within CDI application.
• If a documentation opportunity is identified, place physician query and follow up for response to ensure completeness and accuracy of the medical record.
• If coding opportunity is identified, coordinate with coder and/or Coding Leadership to review and address opportunity as applicable.
• Serves as a role model and resource for CDI team members.
• Subject matter expert that exhibits excellent skills in essential components of the CDI Specialist role.
• Responds to CDS requests for concurrent chart reviews on challenging cases with recommendations and supporting rationale.
• Performs concurrent second level reviews based on defined criteria and shares feedback with CDI Specialist assigned to the encounter for action on opportunities identified.
• Maintains a summary of opportunities identified through second level review for feedback and education with the CDI team.
• Coordinates with other Second Level Reviewers, CDI Leads, and CDI Educator to compile trends and areas of opportunity and conduct education both 1:1 and group education with the CDI team based on the findings.
• Periodically review the criteria established for cases triggering a second level review and recommend updates or modifications to the criteria to assist in identifying areas of opportunity.
• Is actively engaged in quality and process improvement efforts.
• Performs targeted audits as assigned in support of department initiatives.
• Participates in quality initiatives such as HAC/PSI and US News/Mortality.
• Collaborates with CDI Leadership, Leads and Educators to optimize query templates.
• Identifies and shares feedback regarding workflow improvement opportunities identified when completing the SLR process.
• Facilitates change and supports the CDI team through change management processes.
• Actively engages in advancing the CDI practice throughout the UH enterprise.
• Actively engages in department and/or enterprise-wide committee.
• Performs other duties as assigned. Complies with all policies and standards.

Clinical Documentation Integrity Analyst

Principal Medical Writer

Clinical Documentation Specialist

RN Clinical Documentation Specialist

Clinical Documentation Specialist

Registered Nurse, Clinical Documentation Specialist – CDIP, CCDS Required