Medical writer

• Facilitate improvement in the quality, completeness, and accuracy of medical record documentation
• Educate patient care teams, Medical Staff, Hospital Staff, and Coding team members on documentation guidelines and clinical updates
• Perform ongoing and follow-up medical record reviews using documentation improvement guidelines
• Evaluate the quality and completeness of clinical documentation
• Interact concurrently with physicians and mid-level providers to obtain more detailed medical-record information
• Ensure severity of illness and level of services are accurately reflected in the medical record
• Review patients’ clinical pictures and assign working DRGs
• Enter working DRGs into the appropriate database/IDX system and track DRG worksheet completion
• Track and analyze documentation improvement outcomes; prepare and present regular progress reports
• Facilitate and participate in team meetings with Coding staff
• Collaborate with inpatient coders on DRG assignment and reimbursement accuracy
• Develop clinical documentation improvement training and performance-improvement programs
• Provide updates as regulations change
• Respond to payors concerning clinical denials
• Provide clinical documentation expertise for outpatient physician-documentation issues
• Perform other assigned duties

Explore Registered Nurse, Clinical Documentation Specialist at Dartmouth-Hitchcock Keene. Review requirements and application details.