Medical writer

• 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

• Support all care teams across the region in comprehensive and targeted chart reviews
• Partner with regional leaders on workflow optimization
• Access and review HIE/EMRs to identify potential suspects based on test results
• Identify the need for Medical Records requests
• Prepare and lead monthly Rejected Suspect Reviews
• Identify and analyze opportunities for improving patient quality outcomes and cost of care
• Monitor clinical documentation efforts
• Other duties, as assigned

Senior Clinical Documentation Specialist

• Develop scientific copy for various deliverables on assigned brands and products
• Work independently and collaboratively with medical writers and directors to develop scientifically accurate copy
• Understand medical strategy and content objectives for assigned projects and accounts
• Proactively check-in with senior medical leads on project deliverables and raise questions as needed
• Review current literature for assigned therapeutics areas, including competitor products
• Understand and adhere to AMA/client style guidelines as directed
• Ensure references are accurate and research additional references or source materials as necessary
• Annotate and highlight references for medical review
• Manage workflow for assigned projects and meet associated deadlines
• Communicate with clients and/or KOLs to present scientific projects for review and feedback
• Incorporate and discuss edits requested by clients, KOLs, and/or internal reviewers
• Attend and participate in kickoff, status, and other job-related meetings
• Collaborate with creative and illustrative team members to make scientific data visually compelling and scientifically accurate
• Provide medical guidance to team by maintaining up to date scientific knowledge for assigned brands and products

Medical Writer

• 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

Senior Medical Writer – Publications

• Set the venture's direction and lead its execution.
• Refine the ICP, pricing model, and product positioning
• Lead pilots with compliance and revenue cycle leaders, convert them to paid engagements, and build the go-to-market motion
• Partner with the FutureSight product and engineering team to ship V1 and iterate on user feedback
• Lead the seed raise, supported by FutureSight's network and traction
• Recruit and lead the founding team, and establish the cultural foundation of the company

Co-Founder & CEO – HealthTech, AI Clinical Documentation Compliance

• Performs as a vital member of the interdisciplinary care team member, an auditor, and an educator ensuring medical records are complete and clinical documentation comprehensively represents the current health status of network patients against ever-changing risk adjusted models.
• Responsible for achieving improved documentation results and risk adjusted scores for the organization, along with documentation and electronic health record charts that accurately capture the clinical picture.
• Reviews clinical records of both clinical documentation integrity and mortality scoring.
• Collaborates with others regarding clinical documentation improvement (CDI) and risk adjustment (mortality) findings.
• Maintains knowledge of Centers for Medicare and Medicaid Services (CMS) requirements related to clinical documentation and provides feedback to clinical staff regarding these requirements during the concurrent record review process.
• Maintains knowledge of mortality models, observed rate/expected rate (O/E ratios), industry trends, variable and diagnosis review group (DRG) frequency.
• Serves as a liaison between coding staff and physicians as appropriate.
• Identifies and initiates opportunities for new program development or program extensions, as well as opportunities based on outcomes analysis for program process improvements.
• Works with other team members regarding opportunities for improvement in standard work.
• Maintains documentation, logs adjusted risk and CDI opportunities.
• Applies the existing body of evidence-based practice and scientific knowledge in health care to nursing practice, ensuring that nursing care is delivered based on patient’s age-specific needs and clinical needs as described in the department's scope of service.
• Works in a constant state of alertness and safe manner.
• Performs other duties as assigned.

Clinical Documentation Specialist, Second Reviewer

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Clinical Documentation Integrity Specialist

• Lead CDI strategy, planning, development, implementation and maintenance of CDI program.
• Manage projects associated with Mid Revenue Cycle and CDI initiatives.
• Maintain processes aligned with regulatory and legal requirements.
• Direct and manage the Clinical Documentation Integrity team.
• Collaborate with Coding and HIM leadership to maximize outcomes.
• Promote physician and provider education, engagement and collaboration.

Director, Clinical Documentation Integrity

• Performs duties of a clinical documentation specialist and serves as a mentor and resource to the clinical documentation improvement team.
• Completes initial reviews of patient records and evaluates documentation to assign the principal diagnosis, pertinent secondary diagnoses, and procedures for accurate Diagnosis Review Group (DRG) assignment, risk of mortality (ROM), and severity of illness (SOI).
• Conducts follow-up reviews of patients to support and assign a working or final DRG assignment upon patient discharge, as necessary.
• Queries physicians regarding missing, unclear, or conflicting health record documentation by requesting and obtaining additional documentation within the health record when needed.
• Educates physicians and key healthcare providers regarding clinical documentation improvement (CDI) and the need for accurate and complete documentation in the health record.
• Trains and mentors new CDI staff on CDI strategy, workflows, and software.
• Partners with the coding professionals to ensure accuracy of diagnostic and procedural data and completeness of supporting documentation to determine a working and final DRG, SOI, and/or ROM.

Lead RN, Clinical Documentation Specialist

• Author technical documents with a high level of detail and precision to support domestic and international regulatory submissions.
• Compile and edit manuscripts on clinical studies and scientific reports including special summaries from approved raw data.
• Incorporate graphs, charts, tables, and statistical analyses from approved source files.
• Proofread, edit, circulate, assemble, and inspect submission documents for accuracy and compliance.
• May prepare responses regarding company products, drugs, or diseases and refers in-depth technical inquiries to medical personnel.
• Communicates and coordinates review and internal approval of the technical documents following department procedures.
• Develop and build package inserts using desktop publishing software following approved department procedures.
• Review labeling for consistency with related products specifications.
• Communicates and coordinates review of the labeling with cross-functional team.

Senior Medical Writer

• Manage complex multi-workstream projects and oversee junior team members
• Analyze data to implement performance improvement and organizational change
• Collaborate with team members and clients to align with business objectives
• Communicate effectively with project teams and stakeholders
• Lead and develop team members through training, supervision, and feedback

Healthcare Manager – Clinical Documentation Improvement

• Performs inpatient chart review to determine appropriate DRG assignment and assures appropriate documentation in the chart
• Coordinates with physicians, nurses, ancillary staff, and the coders in Health Information Management
• Documents findings within Carle CDI software
• Assures documentation in the chart represents a true clinical picture of the patient diagnoses
• Reviews denials for accurate and complete documentation and develops appeal letter when needed

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