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

• Improves the accuracy and completeness of clinical documentation in medical records
• Performs thorough reviews and requests clarifications from clinicians
• Facilitates modifications that accurately reflect patient severity, risk, and resource use
• Collaborates with clinicians and coders
• Ensures compliance with regulatory guidelines
• Supports accurate reporting of provider and hospital outcomes
• Actively contributes to operational improvements
• Participates in education and program-related activities

Clinical Documentation Specialist

• Conducts concurrent and retrospective reviews of patient medical records to evaluate the accuracy and completeness of clinical documentation, ensuring notes reflect the severity of patient's illness and quality of care.
• Interacts thoughtfully and effectively with physicians, patient care team, and ancillary departments to gather and clarify medical record documentation.
• Identifies opportunities for improvement to ensure understanding of documentation requirements, optimize reimbursement for the level of service rendered, and enhance the measurement and reporting of outcomes.

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Clinical Documentation Specialist, First Reviewer

Clinical Documentation Specialist

Clinical Documentation Specialist