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

• Collaborates with physician, mid-level providers, ancillary staff, and medical records coders to identify principle and secondary diagnoses, and principle procedures
• Reviews for quality indicators
• Conducts initial and ongoing concurrent and some retrospective reviews for system wide admissions for all payors
• Identifies when there is a need to clarify documentation in patient records and initiates queries or communication with providers
• Provides information and education as necessary to providers on an ongoing basis
• Collaborates with Physician Advisor to present education

Clinical Documentation Specialist

• Reviews medical record for completeness and accuracy for severity of illness (SOI) and quality using the clinical documentation improvement strategies.
• Performs accurate and timely medical record review.
• Recognizes opportunities for documentation improvement.
• Initiates clinical documentation improvement severity worksheet for inpatients.
• Formulates clinically credible documentation clarifications.
• Requests documentation clarifications as appropriate for SOI, core measures, and patient safety.
• Follows up timely on all cases and resolution of those cases with clinical documentation clarifications.
• Participates in task force meetings.
• Communicates with HIM coding staff and resolves discrepancies
• Accurately inputs data into electronic clinical documentation improvement tool.
• Understands and support clinical documentation improvement strategies.
• Maintains current knowledge/certification.

RN Specialist – Clinical Documentation

• Reports to the Market Clinical Documentation Specialist Manager
• Works collaboratively with medical, nursing and ancillary staff, case managers and coders
• Improves accuracy, quality and completeness of clinical documentation
• Performs initial and follow up reviews of selected patient accounts
• Ensures accuracy and completeness of clinical information for quality services
• Oversees clinical documentation patterns and trends
• Educates members of the patient care team regarding clinical documentation needs
• Develops and conducts education for new staff including case managers, coders, physicians, residents, nursing and allied health professionals
• Compiles, analyzes, and evaluates quality and clinical data

• Performs concurrent analytical reviews of clinical and coding data to improving physician documentation for all conditions and treatments from point of entry to discharge.
• Facilitates the resolution of queries and educates members of the patient care team regarding documentation guidelines.
• Collaborates with coding professionals to ensure accuracy of diagnostic and procedural data.
• Completes initial reviews of patient records and evaluates documentation to assign the principal diagnosis.
• Maintains appropriate productivity level.
• Conducts follow-up reviews of patients to assign a working or final DRG assignment upon patient discharge.
• Queries physicians regarding missing, unclear, or conflicting health record documentation.
• Identifies issues with reporting of diagnostic testing proactively.
• Enhances expertise in query development, presentation, and standards.
• Educates physicians and key healthcare providers regarding clinical documentation improvement.
• Attends department meetings to review documentation related issues.
• Conducts independent research to promote knowledge of clinical topics and coding guidelines.
• Collaborates with coding to reconcile the DRG and resolves mismatches.

Clinical Documentation Specialist, First Reviewer

• 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

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