Medical writer

• Facilitating the improvement in the overall quality and completeness of provider-based clinical documentation in the medical record
• Assisting treating providers to ensure documentation accurately reflects diagnostic-related group, severity of illness, risk of mortality, risk adjustment, and complexity of patient care rendered
• Conducting accurate and timely concurrent record reviews
• Ensuring data integrity of the clinical documentation database
• Educating customers through presentations and reports on documentation opportunities

RN Clinical Documentation Specialist

• The Senior Medical Writer is responsible for the development of medical writing deliverables that support the clinical regulatory writing portfolio
• Preparing/Updating/Merging RMPs/Company Core-RMPs (CC-RMPs)
• Managing scheduled and unscheduled aggregate reports including but not limited to Periodic Safety Update Reports (PSURs)
• Conducting critical appraisal and systematic review of literature with a focus on background epidemiology
• Performing aggregate report compliance activities including quality review
• Coordinates and liaises with the members of Study Management Team (SMT)
• Prepares clear and accurate narratives based on Clinical Database and Safety Database outputs provided by the client
• Responsible for the end-to-end signal management process

Senior Medical Writer – Regulatory Writing

• Provides clinically based, concurrent and retrospective reviews of inpatient medical records.
• Ensures documentation accurately reflects quality of care, severity of illness and risk of mortality to support compliant coding, reimbursement, quality reporting, and denials prevention initiatives.
• Proactively contacts physicians or other clinicians as needed to clarify procedures/diagnoses to ensure proper documentation.
• Performs initial case reviews and follow up reviews.
• Submits compliant provider queries as needed to clarify documentation of relevant diagnoses, procedures, clinical indicators, present-on-admission status, acuity, specificity, and treatment in accordance with ACDIS/AHIMA compliant query guidance and organizational policy.
• Applies knowledge of ICD-10-CM/PCS Official Guidelines for Coding and Reporting, AHA Coding Clinic, MS-DRG/APR-DRG methodology, CC/MCC capture, SOI/ROM, and quality indicators to support an accurate working DRG in collaboration with Coding/HIM.
• Promotes a partnership with Coding/HIM team to ensure the accuracy of principal diagnosis, procedures, and completeness of documentation to determine the working and final DRG, severity of illness and risk of mortality.
• Functions as a liaison between clinical and coding teams.
• Actively engages and participates in delivery of education to providers through extensive interaction one on one.
• Utilizes critical thinking skills and clinical reasoning to identify, clarify, and query accurate representation of documentation to reflect appropriate clinical status of the patient which will translate into quality reporting, physician report cards, reimbursement, public health data, and disease tracking and trending.

Clinical Documentation Specialist

• Review high-acuity patient medical records to identify clinical indicators, documentation gaps, and suspect diagnoses that may impact quality outcomes, risk adjustment, and reimbursement.
• Analyze medical records to determine appropriate clinical information and identify opportunities for accurate diagnosis capture and documentation improvement.
• Implement and execute clinical data review strategies in alignment with established protocols, program requirements, and organizational standards.
• Ensure consistency, accuracy, and adherence to documentation review methodologies within assigned protocols while contributing to the development and implementation of new review processes.
• Utilize clinical expertise and coding knowledge to identify opportunities for enhanced documentation accuracy, completeness, and specificity.
• Collaborate with risk adjustment, case management, quality, and provider teams to ensure clinical documentation accurately reflects patient conditions, treatment decisions, and diagnoses.
• Leverage physician query and communication processes to clarify documentation and improve the quality and completeness of the medical record.
• Identify and validate suspect diagnoses using clinical evidence and documentation standards.
• Communicate clinical documentation requirements, coding guidelines, and regulatory standards to providers, coders, leadership, and other stakeholders.
• Support coding validation efforts by ensuring documentation supports reported diagnoses and conditions.
• Assist with provider and staff education regarding documentation improvement, coding compliance, risk adjustment methodologies, and diagnosis capture initiatives.
• Maintain comprehensive tracking and management systems for assigned medical record reviews, findings, and outcomes.
• Generate reports and communicate findings resulting from chart reviews to leadership and relevant stakeholders.
• Monitor and maintain productivity, quality, and accuracy standards as defined by organizational performance metrics.
• Ensure all activities comply with HIPAA regulations, CMS guidelines, payer requirements, and organizational policies.
• Participate in internal audits, quality assurance activities, and process improvement initiatives.

Clinical Documentation Integrity Review

• The Clinical Documentation Integrity Specialist (CDIS) Lead is an advanced level position for the experienced and proficient CDI Specialist consistently meeting or exceeding all criteria for CDIS advanced performance.
• The CDIS Lead provides support to CDI leadership within a defined scope of facilities and CDI team.
• The CDIS Lead serves as a liaison between senior leadership, medical staff, nursing, coding, case management and quality departments.
• Key Responsibilities: May be assigned special projects related to CDI processes, quality, data analysis, or HIM/CDI performance.
• Assumes responsibility for daily workflow process and adjustments for the CDI team.
• May present CDI performance metrics at facility meetings.
• May present CDI education as needed.
• Will assume operational oversight in the absence of the CDI Director.
• Supports CDI team through multidisciplinary approach in support of program goals.
• Facilitates collaborative efforts between CDI, HIM and Medical Staff providers.
• Facilitates collaborative efforts between CDI and clinical teams such as Quality and Case Management.
• Effectively utilizes leadership abilities and critical thinking skills to identify opportunities for team process and engagement optimization.
• Maintains professional competency in documentation and coding practices by keeping up to date with new coding guidelines, policies/procedures, federal and state reimbursement.

Clinical Documentation Integrity Specialist – Lead

• Deliver formal education to staff and providers
• Develop impactful learning modules
• Conduct audits to ensure accuracy and continuous improvement
• Assist with onboarding new hires
• Provide ongoing, continuing education and competency assessments
• Perform concurrent, retrospective, and secondary clinical chart reviews

RN Clinical Documentation Education – Compliance Consultant

• Lead end-to-end development of scientific publications, including manuscripts, abstracts, posters, plain language summaries, and congress materials
• Translate publication plans into executable content; identify scientific storylines and recommend approaches to clients and authors
• Ensure compliance with ICMJE, GPP 2022, and journal-specific requirements; serve as a guidelines resource for the wider team
• Translate complex clinical and scientific data into clear, concise, and accurate content for expert audiences — and for lay audiences where required
• Conduct literature reviews and contribute to data interpretation that informs both content and strategy
• Maintain consistency in messaging, tone, and scientific accuracy across deliverables and across an account
• Own author and steering committee engagement, including kickoff meetings, content reviews, and consensus-building across multi-author teams
• Partner with account, strategy, and scientific leads to shape content direction; contribute to scope development and new business work as needed
• Mentor junior writers through structured review, coaching, and onboarding; act as a quality checkpoint on team deliverables
• Build and maintain therapy area expertise; act as a scientific point of contact for an assigned franchise or account
• Apply AI-enabled writing, literature review, and analytics tools thoughtfully and in line with Real Chemistry's responsible-use standards
• Deliver projects on time and to a high standard, proactively managing workload, surfacing risks early, and adapting to changing priorities without compromising quality

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