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

• Provides clinically based, concurrent and retrospective reviews of inpatient medical records.
• Ensures documentation accurately reflects quality of care, severity of illness and risk of mortality to support compliant coding, reimbursement, quality reporting, and denials prevention initiatives.
• Proactively contacts physicians or other clinicians as needed to clarify procedures/diagnoses to ensure proper documentation.
• Performs initial case reviews and follow up reviews.
• Submits compliant provider queries as needed to clarify documentation of relevant diagnoses, procedures, clinical indicators, present-on-admission status, acuity, specificity, and treatment in accordance with ACDIS/AHIMA compliant query guidance and organizational policy.
• Applies knowledge of ICD-10-CM/PCS Official Guidelines for Coding and Reporting, AHA Coding Clinic, MS-DRG/APR-DRG methodology, CC/MCC capture, SOI/ROM, and quality indicators to support an accurate working DRG in collaboration with Coding/HIM.
• Promotes a partnership with Coding/HIM team to ensure the accuracy of principal diagnosis, procedures, and completeness of documentation to determine the working and final DRG, severity of illness and risk of mortality.
• Functions as a liaison between clinical and coding teams.
• Actively engages and participates in delivery of education to providers through extensive interaction one on one.
• Utilizes critical thinking skills and clinical reasoning to identify, clarify, and query accurate representation of documentation to reflect appropriate clinical status of the patient which will translate into quality reporting, physician report cards, reimbursement, public health data, and disease tracking and trending.

Clinical Documentation Specialist

• This position is responsible for concurrent review of inpatient medical records in order to identify opportunities for improving the quality of physician documentation
• Facilitates modifications to clinical documentation through concurrent interaction with physicians (face-to-face and electronically) and other members of the health care team
• The goal of this position is to achieve a complete medical record in order to support complete, accurate and timely coding
• Communicates with physicians, case managers, coders, and other healthcare team members to facilitate comprehensive medical record documentation to reflect clinical treatment, decisions, and diagnoses for inpatients
• Utilizes the hospital’s designated clinical documentation system to identify opportunities for physician and hospital outcomes
• Provides or coordinates education to all internal customers related to compliance, coding, and clinical documentation issues and acts as a consultant to coders when additional information or documentation is needed to assign the correct DRG
• Responsible for the day-to-day evaluation of documentation by the medical staff and healthcare team in accordance with the hospital’s designated clinical documentation system
• Gathers and analyzes information pertinent to documentation findings and outcomes
• Contributes to a positive working environment and performs other duties as assigned or directed to enhance the overall efforts of the organization
• Develops physician education strategies to promote complete and accurate clinical documentation and correct negative trends
• Identifies patterns, trends variances and opportunities to improve documentation review and process
• Researches literature and stays abreast of CMS rules and regulations, incorporating changes to daily practice for overall documentation enhancement
• Assists in the development and reporting of performance measures to the medical staff and other departments and prepares physician specific data information
• Conferences with key physicians to review outcome information (including physician profile data if relevant) as it relates to documentation clarity, completeness, and correct DRG designation
• Coaches physicians to improve their documentation so it more accurately reflects intensity of services and severity of illness
• Documents conference and results
• Attends various hospital service line meetings, reviewing outcome information, and educating physicians on service line specific improvement opportunities
• Complies with HIPAA and Code of Conduct policies
• Assists with special projects as needed
• Demonstrates competency for individual performance and development in the following areas: Customer Service, Job Skills, Resource Management, Teamwork, and Innovation
• 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

• 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

Medical writer jobs in Texas

See all jobs on JobTailor

RN Clinical Documentation Specialist

Clinical Documentation Specialist

Clinical Documentation Specialist

Clinical Documentation Auditor – Educator

Clinical Documentation Specialist, First Reviewer

Clinical Documentation Integrity Specialist – Lead

RN Clinical Documentation Education – Compliance Consultant

Clinical Documentation Specialist