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

• The Clinical Documentation Integrity Specialist (CDIS) Lead is an advanced level position for the experienced and proficient CDI Specialist consistently meeting or exceeding all criteria for CDIS advanced performance.
• The CDIS Lead provides support to CDI leadership within a defined scope of facilities and CDI team.
• The CDIS Lead serves as a liaison between senior leadership, medical staff, nursing, coding, case management and quality departments.
• Key Responsibilities: May be assigned special projects related to CDI processes, quality, data analysis, or HIM/CDI performance.
• Assumes responsibility for daily workflow process and adjustments for the CDI team.
• May present CDI performance metrics at facility meetings.
• May present CDI education as needed.
• Will assume operational oversight in the absence of the CDI Director.
• Supports CDI team through multidisciplinary approach in support of program goals.
• Facilitates collaborative efforts between CDI, HIM and Medical Staff providers.
• Facilitates collaborative efforts between CDI and clinical teams such as Quality and Case Management.
• Effectively utilizes leadership abilities and critical thinking skills to identify opportunities for team process and engagement optimization.
• Maintains professional competency in documentation and coding practices by keeping up to date with new coding guidelines, policies/procedures, federal and state reimbursement.

Clinical Documentation Integrity Specialist – Lead

• 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

• 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

Clinical Documentation Specialist III – Registered Nurse

• Lead risk adjustment coding reviews, audits, and education programs that drive coding accuracy, regulatory compliance, and clinical documentation improvement (CDI) across the organization
• Conduct regular audits of risk adjustment coding/auditing practices, identify gaps, and provides targeted training and support to resolve them
• Analyze coding data to detect trends, patterns, and compliance risks, then translate findings into actionable improvements that reduce errors and strengthen risk adjustment practices
• Monitor changes in coding regulations and policies, and ensure timely organizational compliance
• Design and deliver coding education programs for staff and clients covering CDI, coding best practices, and regulatory compliance
• Define key metrics and performance indicators, monitor operating results, and drive corrective action/performance coaching when targets are not met
• Lead recruitment, onboarding, and ongoing development of coding/auditing staff, ensuring performance management practices align with applicable laws and regulations
• Own escalated coding/auditing and compliance issues through to timely, appropriate resolution
• Partner with internal departments to align on service standards and support consistent, high-quality coding/auditing outcomes
• Document and improve coding/auditing processes and workflows to increase efficiency and consistency
• Track and report on coding/auditing performance metrics, ensuring full adherence to policies and governmental and HIPAA compliance requirements
• Handle all Protected Health Information (PHI) in strict accordance with HIPAA requirements

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Clinical Documentation Specialist, First Reviewer

Clinical Documentation Integrity Specialist – Lead

RN Clinical Documentation Education – Compliance Consultant

Clinical Documentation Specialist III – Registered Nurse

Manager, Clinical Documentation and Coding Accuracy