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

• 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

• Utilizes advanced clinical and coding expertise to direct efforts toward the integrity of clinical documentation through the roles of reviewer, educator and consultant.
• Facilitates the overall quality, completeness, accuracy and integrity of medical record documentation through extensive record review.
• Through extensive interaction with physicians and other members of the healthcare team, achieves appropriate clinical documentation to support code assignment, medical necessity, severity of illness, risk of mortality and level of services rendered to all patients.
• Participates in the development and delivery of education for providers and members of the healthcare team.

Clinical Documentation Specialist – CDI

• Supervises daily operations of the CDI program for the Health Ministries within their region
• Provides direct oversight of the Clinical Documentation Specialist and Coordinator
• Ensures compliance with Trinity Health System Office CDI program standards
• Monitors quality and productivity
• Provides training and education to clinical documentation specialists
• Collaborates with Clinicians, Coding, Quality and Denials teams to facilitate documentation

Supervisor, Clinical Documentation Integrity

• Under minimal supervision, the Medical Writer will critically evaluate, analyze, and interpret the medical literature to select primary resource materials for adequate study design, statistical significance, scientific rigor and absence of bias
• Write and edit clinical development documents, including but not limited to, clinical protocols, investigator’s brochures, clinical study reports, subject consent forms, integrated safety and efficacy summaries, Module 2.7.1, 2.7.2, 2.7.3, 2.7.4, and 2.5 documents, presentation materials and publications to medical journals
• Complete writing assignments in a timely manner
• Maintain timelines and workflow of writing assignments
• Practice good internal and external customer service
• Highly proficient with styles of writing for various regulatory documents
• Expert proficiency with client templates & style guides
• Interact directly and independently with client to coordinate all facets of projects; competent communicator skills for projects
• Contribute substantially to, or manages, production of interpretive guides
• Take ownership of a given assignment, proactively consulting other project team members and other department representatives for information or guidance as necessary
• Mentor medical writers and other members of the project team who are involved in the writing process

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Clinical Documentation Specialist, First Reviewer

RN Clinical Documentation Education – Compliance Consultant

Clinical Documentation Specialist – CDI

Supervisor, Clinical Documentation Integrity

Senior Medical Writer