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

• 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.

• 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

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