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

• Write, edit, and manage manuscripts, posters, abstracts, oral presentation slide decks, and review articles, on time, within budget, and with little instruction
• Raise and help resolve project management issues, such as out-of-scope requests
• Ensure compliance with quality processes and industry standards
• Represent the team as the lead contact on projects
• Lead or provide input on process improvements

Senior Medical Writer, Publications

• Provide strategic and operational leadership for all CDI functions across the health system
• Develop and implement CDI strategies that support documentation integrity, quality outcomes, reimbursement optimization, regulatory compliance, and clinical validation
• Collaborate with physician leadership, Hospital Coding, Case Management, Quality, Compliance, Information Technology, and Revenue Cycle teams to improve documentation accuracy and operational performance
• Lead provider education and engagement initiatives related to clinical documentation standards, regulatory requirements, quality metrics, and reimbursement methodologies
• Oversee CDI technology initiatives, including AI-enabled CDI tools, analytics platforms, EHR optimization, and provider documentation template/content support
• Monitor and analyze CDI performance metrics including CMI, SOI/ROM, query activity, quality indicators, and reimbursement impact to drive continuous improvement
• Ensure CDI policies, procedures, workflows, and internal controls comply with organizational, state, and federal requirements
• Lead, develop, and support CDI staff through performance management, training, and professional development initiatives
• Manage departmental budget, vendor relationships, staffing resources, and operational priorities
• Support organizational culture initiatives that promote collaboration, accountability, diversity, equity, inclusion, and continuous improvement

Director, PRMO Clinical Documentation Integrity

• Assesses clinical documentation through extensive review of the medical record
• Interacts with providers, nursing staff, and coding staff to ensure appropriate reimbursement
• Conducts post discharge reconciliation for comparative analysis of CDI specialist and final coding
• Formulates appropriate clinical documentation clarifications
• Works with providers and Advanced Practitioners to improve documentation
• Participates in departmental education, training, and orientation sessions
• Assists in overall quality and completeness of the health record

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Clinical Documentation Specialist, First Reviewer

RN Clinical Documentation Education – Compliance Consultant

Senior Medical Writer, Publications

Director, PRMO Clinical Documentation Integrity

Clinical Documentation Specialist III – Registered Nurse