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

• 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 and the need for accurate and complete documentation.
• Collaborates with 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.
• 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).
• Maintains appropriate productivity level. Conducts follow-up reviews of patients every 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.
• Identifies issues with reporting of diagnostic testing proactively. Enhances expertise in query development, presentation, and standards including understanding of published query guidelines and practice expectations for compliance.
• Educates physicians and key healthcare providers regarding clinical documentation improvement and the need for accurate and complete documentation in the health record.
• Conducts independent research to promote knowledge of clinical topics, coding guidelines, regulatory policies and trends, and healthcare economics.
• Collaborates with coding to reconcile the DRG and resolves mismatches utilizing the escalation policy.
• Troubleshoots documentation or communication problems proactively and appropriately escalates.
• Evaluates clinical issues in the health record with the coding professionals that would support an accurate DRG assignment, SOI, and/or ROM.
• Assists in the mortality review and risk adjustment process utilizing third-party models.

Clinical Documentation Specialist, First Reviewer

• Writes, edits, and coordinates content for clinical/regulatory documents
• Leads the clear and accurate completion of medical writing deliverables
• Manages medical writing activities associated with individual studies
• Completes a variety of documents that may include clinical study protocols, clinical study reports, patient narratives, annual reports, investigator brochures, informed consents, and more
• Leads the resolution of comments from the client
• Acts as peer reviewer for internal team to ensure document scientific content, clarity, overall consistency, and proper format
• Interacts and builds good working relations with clients, department head, and peers in data management, biostatistics, regulatory affairs, and medical affairs
• May contribute to development of internal materials and presentations or changes to internal process, standard practices, and capabilities
• Mentors and leads less experienced medical writers on complex projects

Medical Writer II – Senior 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.

• 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

Medical writer jobs in Montana

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RN Clinical Documentation Specialist

Clinical Documentation Specialist

Clinical Documentation Specialist, First Reviewer

Medical Writer II – Senior Medical Writer

Clinical Documentation Specialist, First Reviewer

RN Clinical Documentation Education – Compliance Consultant