Medical writer

• Facilitate the overall quality, completeness, and accuracy of clinical documentation through concurrent interaction with providers and other members of the healthcare team.
• Ensure documentation accurately reflects patients’ clinical conditions and level of service.
• Communicate with providers through discussion and/or compliant queries to address missing, unclear, conflicting, or clinically unsupported diagnoses.
• Assign MS-DRG/APR-DRG appropriately.
• Evaluate severity of illness (SOI) and risk of mortality (ROM).
• Identify relevant clinical indicators, including HACs and PSIs.
• Apply principles of clinical validation.
• Ensure queries comply with AHIMA/ACDIS guidelines and the CDI Code of Ethics.

Clinical Documentation Integrity Specialist

• Facilitate the overall quality, completeness, and accuracy of clinical documentation through concurrent interaction with providers and other healthcare team members
• Ensure documentation accurately reflects patients’ clinical conditions and level of service
• Communicate with providers through discussion and/or compliant queries to address missing, unclear, conflicting, or clinically unsupported diagnoses
• Assign MS-DRG/APR-DRG and assess severity of illness (SOI) and risk of mortality (ROM)
• Identify relevant clinical indicators, including HACs and PSIs
• Apply principles of clinical validation
• Ensure queries comply with AHIMA/ACDIS guidelines and the CDI Code of Ethics