Nuvance Health

Medical writer

• Facilitate improvement in the quality, completeness and accuracy of medical record documentation
• Obtain and promote appropriate clinical documentation through interaction with physicians, nursing staff, patient caregivers, coding and Health Information Management teams
• Perform admission reviews for specific patient populations using clinical documentation guidelines
• Review physician and clinical documentation, lab results, diagnostic information and treatment plans; capture appropriate information in 3M
• Identify documentation opportunities reflecting severity of illness, acuity and resource consumption
• Communicate with physicians to clarify documentation opportunities and post physician queries using AHIMA-approved format
• Update 3M for changes in patient status, procedures, treatments, physician documentation, lab findings and diagnostic results
• Confer with physicians regarding severity of illness, principal diagnosis, comorbid conditions, complications and procedures
• Collaborate with coding staff to determine appropriate DRG and required documentation
• Provide clinical expertise and references to coding staff
• Conduct ongoing education regarding the clinical documentation integrity program and assist with educating new staff and clinical personnel
• Track and trend personal performance using 3M data and review performance against established benchmarks
• Participate in educational conferences, performance improvement activities and ongoing medical record review
• Maintain communication with physicians, interdisciplinary care team members, department leadership and coding staff
• Demonstrate regular, reliable and predictable attendance
• Perform other duties as required

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Clinical Documentation Improvement Specialist