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

• Provides onsite and remote clinical documentation integrity (CDI) support to the Health Ministry (HM) CDI programs as part of the System Office CDI Float Pool.
• Utilizes advanced coding and/or clinical expertise to direct efforts toward the improvement and integrity of clinical documentation.
• Responsible for reviewing and/or auditing medical record clinical documentation to support the medical necessity, severity of illness, risk of mortality, accurate coding, clinical evidence, resources consumed, and level of services rendered to all patients.
• Audits HM CDSs for query compliance, workflow and missed documentation opportunities.
• Trains end users in the use of CDI system software, standards, and workflow.
• Demonstrates understanding of and facilitates appropriate clinical documentation to ensure that the medical necessity, severity of illness, risk of mortality, accurate coding, clinical evidence, resources consumed, and level of services provided are accurately reflected in the health record.
• Conducts clinical documentation chart reviews and queries providers as appropriate to support RHMs staffing needs.
• Reviews may be conducted on site or remotely.
• Follows HM CDI Program workflow and processes and communicates with local CDI Team to support local operations.
• Communicates with physicians and other members of the healthcare team at the HM regarding clinical documentation as part of local CDI Team assignment.
• Audits medical records, queries, CDS and coder assigned codes, CDI software entries, etc., as requested to provide feedback to the HMs for improvement opportunities.
• Trains end users in the use of CDI system software, standards, and workflow.
• Provides documentation education to providers and members of healthcare team at the RHM as part of CDI Team assignment or as requested.
• Demonstrates ability to quickly learn and master the various CDI technology applications, systems and workflows in place across the enterprise.
• Provides expertise in problem-solving skills based on theoretical knowledge, clinical experience and sound judgment and serves as a professional role model by demonstrating desirable practice behaviors.
• Assists the System Office Clinical Documentation Manager with all aspects of the CDI program across the system including data collection and maintenance of the CDI Dashboard.
• May develop educational content for providers and CDSs on CDI workflow and processes, CDI and Physician software systems, and documentation and coding guidelines as requested.
• Performs other duties as assigned by leadership.

Clinical Documentation Specialist, Audit Coordinator

• Supervises daily operations of the CDI program for the Health Ministries (HMs) within the region.
• Provides direct oversight of the Clinical Documentation Specialist and Clinical Documentation Integrity Coordinator.
• Ensures that defined goals are accomplished utilizing timely and compliant processes within the region.
• Trains and educates clinical documentation specialists (CDS) to enhance clinical and coding skill sets.
• Responsible for scheduling and work assignments for colleagues.
• Collaborates with Clinicians, Coding, Quality and Denials teams to facilitate documentation within the medical record.

Supervisor, Clinical Documentation Integrity

• 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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