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

• Evaluating overall completeness and quality of clinical documentation
• Works in partnership with physicians, coders, and other healthcare professionals
• Performs concurrent review process for all selected admissions
• Demonstrates in-depth clinical knowledge of complex disease processes and procedures in an inpatient setting
• Utilize current CMS, AHA, and AHIMA coding guidelines to accurately determine diagnoses and procedures
• Develop documentation query protocol and educate essential staff
• Initiates assertive communication with physicians when documentation requires clarification
• Tracks responses and trends compliance with documentation queries
• Identifies trends in documentation and/or potential problems and develops action plans
• Works effectively with coding staff to clarify documentation issues
• Provides information and education to physicians not responding to documentation requests
• Conducts independent research to promote knowledge of clinical topics and trends

• 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

Medical writer jobs in Oklahoma

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RN Clinical Documentation Specialist

Clinical Documentation Specialist

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Clinical Documentation Specialist, First Reviewer

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