Medical writer

• Facilitate improvement system-wide in the overall quality, completeness, and accuracy of the medical record documentation through extensive audit investigation, education and data analysis
• Responsible for identification of patterns, trends, and opportunities for the entire CDI team, at all acute care facilities, to improve accuracy and outcomes
• Responsible for assisting with large retrospective audits, at the request of hospital clients system-wide, and for educating physicians, if needed
• Audits case reviews and queries of Clinical Documentation Specialists (CDIS) to ensure quality and compliance, using audit tools developed
• Tracks, trends, and reports audit findings for each Clinical Documentation Specialist (CDIS), Hospital Region, and System-wide to Director/management team
• Identifies knowledge gaps and provides clear explanations and interpretations on missing, unclear, conflicting, or non-compliant information captured by the CDIS
• Researches, investigates and remains up to date on both clinical and coding guidelines in quarterly Coding Clinics as they relate to physician documentation improvement needed, in an ICD-10 coding environment
• Assists in overall quality, timeliness and completeness of the quality health record to ensure appropriate data, provider communication, and quality outcomes
• Serves as a resource for appropriate clinical documentation
• Develops presentation material and provides training and education to physicians and CDIS staff as needed in an effort to strengthen documentation practices and ensure accurate coding that reflects the severity of illness (SOI) and risk of mortality (ROM) of patients they serve
• Responsible for using audit tools to conduct clinical quality audits
• Develops and updates policies and procedures around the CDIS audit function; and refines audit tools as needed in collaboration with Director/management team
• Collaborates with leadership to conduct focused post-discharge documentation and coding audits as requested by hospital clients system-wide
• Ensures safe care to patients, staff and visitors; adheres to all Memorial Hermann policies, procedures, and standards within budgetary specifications including time management, supply management, productivity and quality of service
• Promotes individual professional growth and development by meeting requirements for mandatory/continuing education and skills competency; supports department-based goals which contribute to the success of the organization; serves as preceptor, mentor and resource to less experienced staff
• Demonstrates commitment to caring for every member of our community by creating compassionate and personalized experiences
• Models Memorial Hermann’s service standards by providing safe, caring, personalized and efficient experiences to patients and colleagues

Clinical Documentation Auditor – Educator

• 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

• Facilitating improvement in the overall quality and completeness of the medical record documentation
• Providing support and expertise through comprehensive assessment and review of inpatient medical records
• Ensuring accurate DRG assignment and obtaining appropriate documentation through interaction with physicians, patient caregivers, and health information management coding staff
• Monitoring home health patients to ensure they meet CMS criteria for services
• Proactive outreach to patients and making recommendations to primary care providers
• Facilitating communication and coordinating care with healthcare providers and caregivers
• Creating positive relationships with home health agencies as well as primary care clinicians

Clinical Documentation Specialist

• Lead the venture's direction and execution
• Refine the ICP, pricing model, and product positioning
• Lead pilots with compliance and revenue cycle leaders, convert them to paid engagements, and build the go-to-market motion
• Partner with the FutureSight product and engineering team to ship V1 and iterate on user feedback
• Lead the seed raise, supported by FutureSight's network and traction
• Recruit and lead the founding team, and establish the cultural foundation of the company

Co-Founder & CEO – HealthTech, AI Clinical Documentation Compliance

• Review, analyze and code diagnostic information in patient charts; identify coding opportunities for improved coding accuracy
• Validate missed coding opportunities
• Ensure compliance with established coding guidelines, third party reimbursement policies, regulations and accreditation guidelines
• Audit patient charts to ensure accurate coding

Clinical Documentation Coder

• Conducts concurrent and retrospective reviews of patient medical records to evaluate the accuracy and completeness of clinical documentation, ensuring notes reflect the severity of patient's illness and quality of care.
• Interacts thoughtfully and effectively with physicians, patient care team, and ancillary departments to gather and clarify medical record documentation.
• Identifies opportunities for improvement to ensure understanding of documentation requirements, optimize reimbursement for the level of service rendered, and enhance the measurement and reporting of outcomes.

See all jobs on JobTailor

Clinical Documentation Auditor – Educator

Clinical Documentation Specialist, First Reviewer

Clinical Documentation Integrity Specialist – Lead

RN Clinical Documentation Education – Compliance Consultant

Clinical Documentation Specialist

Co-Founder & CEO – HealthTech, AI Clinical Documentation Compliance

Clinical Documentation Coder

Clinical Documentation Specialist