Medical writer

• Provide concurrent clinical review of inpatient medical records
• Ensure accurate and complete documentation of diagnoses and procedures
• Review clinical information
• Assign appropriate codes
• Support quality assurance and reporting efforts
• Provide education to providers and staff on clinical documentation
• Build positive relationships with physicians while providing guidance in a respectful, non-confrontational manner

Clinical Documentation Specialist – Medical Records

• Conduct concurrent and retrospective reviews of medical record documentation for accuracy, completeness, patient condition, and services performed
• Support accurate ICD-10-CM/PCS coding, DRG assignment, severity of illness, risk of mortality, reimbursement, risk adjustment, and quality reporting
• Collaborate with coding, physicians, physician advisors, quality teams, utilization management, revenue cycle, and clinical teams
• Deliver documentation education to providers, including risk stratification, chronic conditions, and billing-supporting documentation
• Develop templates, smart phrases, and other documentation tools with clinical teams
• Monitor and improve patient chart documentation in inpatient and outpatient settings
• Review inpatient records within 2 days of admission and identify documentation opportunities and problem-list inaccuracies
• Attend multidisciplinary patient rounds
• Communicate documentation opportunities and ICD-10 specificity through verbal or written queries; track queries and response rates in Epic
• Design and implement EHR documentation tools and educational programs with the physician champion
• Arrange education for new providers after onboarding
• Identify documentation trends and improvement opportunities and report them to attending groups
• Maintain expert knowledge of EHR clarification, presentation, and tracking tools and current ICD-10 requirements
• Understand APR-DRG and MS-DRG methodologies
• Review denials and identify root causes
• Identify strategies for sustained process changes supporting complete and accurate clinical documentation
• Maintain communication with hospital and professional billing coding staff, coding integrity, physician champion, and division leaders

Clinical Documentation Specialist

• Prepare high-quality regulatory documentation for client submissions
• Contribute to authorship of documents across different service lines
• Lead projects and author regulatory documents for client engagements
• Mentor others in regulatory document authoring
• Author and lead Modules 3 and Module 2.3
• Serve as document lead for submission-level documents
• Provide subject matter guidance on document preparation, review, comment resolution, and finalization
• Lead project teams toward goals within timelines and budgets
• Build professional client relationships and support business relationships
• Identify and institutionalize effective work practices
• Resolve sensitive or high-pressure project problems
• Transfer knowledge across the organization

Principal Medical Writer – CMC Focus

• Direct efforts toward the integrity of clinical documentation as a reviewer, educator and consultant
• Facilitate the quality, completeness and accuracy of medical record documentation through extensive record review
• Demonstrate understanding of documentation requirements so severity of illness, risk of mortality, quality indicators and level of services are accurately reflected
• Communicate with and educate physicians and healthcare team members on clinical documentation
• Monitor provider engagement
• Conduct concurrent reviews of selected patient health records for legibility, clarity, completeness, consistency and precision
• Formulate compliant clarifications/queries following Trinity Health's documentation integrity procedures
• Incorporate Trinity Mission, Vision and Values into behaviors, practices, standards, policies, procedures and decisions

• Provide nursing clinical documentation specialist services at St. Joseph’s University Medical Center
• Support the academic tertiary care medical center and state-designated trauma center’s clinical operations

Nurse Clinical Documentation Specialist

• Translate complex medical/scientific concepts into clear, concise copy
• Create branded HCP campaign materials including websites, detail aids, leave behinds, and emails
• Create HCP medical education campaign materials including slide decks, invites, workbooks, and other collateral
• Lead brands from both strategy and copy perspectives with minimal oversight
• Drive the editorial process from first draft to final proof; ensure accuracy and quality
• Partner with design, strategy, account, and project management teams
• Ensure all content is on-brand and compliant with US regulatory and industry standards
• Drive copy and strategic perspectives in client meetings
• Manage competing priorities
• Research and develop content for proposals and pitch presentations
• Stay up to date on current trends in medical education and the US pharma industry

Senior Medical Copywriter

• Utilize clinical and coding expertise to support the integrity of clinical documentation as reviewer, educator and consultant
• Facilitate the quality, completeness and accuracy of medical record documentation through extensive record review
• Demonstrate understanding of documentation needed to accurately reflect severity of illness, risk of mortality, quality indicators and level of services
• Communicate with and educate physicians and healthcare team members on clinical documentation
• Monitor provider engagement
• Conduct concurrent reviews of selected patient health records for legibility, clarity, completeness, consistency and precision
• Formulate compliant clarifications/queries according to Trinity Health documentation integrity procedures
• Incorporate the Trinity Mission, Vision and Values into behaviors, practices, standards, policies, procedures and decisions

• Initiate and perform concurrent documentation reviews of selected inpatient records to clarify conditions, diagnoses, and procedures where inadequate or conflicting documentation is suspected
• Meet or exceed defined performance standards for chart reviews and queries
• Educate physicians, clinicians, and other involved parties on complete and clear documentation of patient care, including complications and comorbidities
• Use queries, face-to-face communications, and educational programs and tools to improve documentation
• Serve as a resource linking ICD-10-CM coding guidelines and medical terminology to accurate final code assignment
• Follow coding and documentation guidelines to ensure physician and hospital compliance
• Maintain current coding knowledge and participate in educational programs and in-services
• Perform CDI Final Review/DRG Reconciliation and report DRG mismatch disagreements for secondary review
• Perform query reconciliation and monitor query outcomes for performance opportunities
• Support the Coding Department by communicating with physicians regarding open queries and acting as liaison between coding and physicians
• Participate in special projects involving physician documentation accuracy
• Precept and mentor new team members
• Collaborate with the Physician Advisor to identify physician documentation issues, query utilization, and education opportunities
• Maintain hospital and departmental policies, performance improvement, safety, environmental, infection control, confidentiality, and security standards
• Perform other related tasks and responsibilities as assigned

• Work closely with the client’s CDI team, supporting classroom education and mentoring
• Ensure successful transfer of CDI best practices from the consulting team to the client team
• Facilitate accurate documentation for severity of illness (SOI) and quality in the medical record
• Interact with physicians, health information management professionals, coding professionals, and nursing staff
• Demonstrate extensive knowledge of clinical documentation requirements, coding guidelines, and workflows applicable to inpatient and outpatient/physician settings
• Conduct comprehensive inpatient medical record reviews for identified payer populations upon admission and throughout hospitalization
• Serve as an educational resource to client CDI teams through classroom education, hands-on teaching, and ongoing mentoring
• Develop and deliver training to physicians, nurses, coding professionals, and ancillary staff on documentation best practices
• Analyze clinical information to identify documentation gaps related to SOI, POA, MS-DRG, APR-DRG, PSI, and quality measures
• Formulate credible and compliant documentation clarifications
• Collaborate with coding teams to ensure accuracy and completeness of documentation and diagnoses
• Support clinical staff through frequent interaction and coaching
• Provide high-quality input for client deliverables and contribute to expert reports
• Provide interim CDS support as needed
• Assist in developing CDI and HIM training tools, methodologies, and education materials
• Demonstrate leadership, manage multiple projects, and contribute to business development and staff development initiatives
• Travel consistently (25%) depending on project requirements and client expectations

Managing Consultant – Clinical Documentation Integrity, Healthcare

• Partner closely with Clinical Scientists on protocols and protocol amendments
• Lead clear and accurate completion of medical writing deliverables
• Manage medical writing activities for individual studies with minimal supervision
• Coordinate medical writing activities across departments
• Lead resolution of client comments
• Write clinical study protocols and amendments, clinical study reports, patient narratives, annual reports, investigator brochures, informed consents, plain language summaries, periodic safety update reports, clinical development plans, IND submissions, integrated summary reports, NDA and eCTD submissions, journal manuscripts, abstracts, posters, and presentations
• Follow ICH E3 guidelines, company SOPs, client standards, approved templates, authorship requirements, and style guides
• Coordinate quality and editorial reviews and manage source documentation
• Lead team document reviews and act as an internal peer reviewer
• Review statistical analysis plans and table/figure/listing specifications
• Collaborate with clients and data management, biostatistics, regulatory affairs, and medical affairs teams
• Perform online clinical literature searches and comply with copyright requirements
• Identify and resolve issues, escalating as appropriate
• Provide technical support, training, and consultation
• Mentor and lead less experienced medical writers
• Develop expertise in industry topics and regulatory requirements
• Monitor budgeted hours and communicate status and changes to medical writing leadership
• Complete required administrative tasks and other assigned duties

Medical writer jobs in United States

Clinical Documentation Specialist – Medical Records

Clinical Documentation Specialist

Principal Medical Writer – CMC Focus

Clinical Documentation Specialist

Nurse Clinical Documentation Specialist

Senior Medical Copywriter

Clinical Documentation Specialist

Clinical Documentation Specialist

Managing Consultant – Clinical Documentation Integrity, Healthcare

Sponsor Dedicated Protocol Medical Writer II/Sr