• Assist the providers with accurately identifying and documenting the healthcare services provided to the patient. • Analyze clinical information, using the documentation as the primary driver for overall System Case Mix Index. • Evaluate the documentation in order to assign the principal diagnosis, relevant secondary diagnoses, and procedures for accurate DRG assignment, risk of mortality, severity of illness. • Formulate queries when there is missing documentation, conflicting documentation or unclear documentation. • Provide ongoing education to physicians and essential healthcare providers regarding clinical documentation improvement. • Collaborate with nursing staff, clinical nutrition, pharmacists, along with the physicians on documentation. • Maintain the confidentiality of all information acquired pertaining to the patient, physician, associates, and visitors.

• Review inpatient medical records to identify documentation gaps and improvement opportunities • Craft physician queries that clarify diagnoses and procedures • Educate providers on documentation best practices and regulatory requirements • Monitor key metrics including CMI trends and query response rates • Support denial management with clinical justifications for appealed claims • Collaborate with coding teams for accurate DRG assignment • Develop documentation policies aligned with CIHQ accreditation standards

This description is a summary of our understanding of the job description. Click on 'Apply' button to find out more. Role Description We are seeking a detail-oriented and highly organized Medical Scribe to join our team. This position supports remote work, providing the opportunity for flexible scheduling and the ability to work from the comfort of your own home. - Accurately and efficiently transcribe medical notes, procedures, and diagnoses into electronic medical records - Assist healthcare providers with documentation during patient appointments - Coordinate communication between healthcare providers and other medical staff - Maintain patient confidentiality and adhere to HIPAA guidelines - Ensure accuracy and completeness of medical records - Perform other administrative tasks as needed Qualifications - Previous experience working as a Medical Scribe or in a similar role - Knowledge of medical terminology and procedures - Strong typing and computer skills - Excellent communication and interpersonal skills - Ability to work independently and prioritize tasks effectively - Attention to detail and accuracy

• Serve as primary author who writes and provides input on routine documents such as clinical study reports and study protocols, and summarizes data from clinical studies. • May research, write or edit complex clinical and scientific and program level documents, including IBs, INDs, and MAAs. • Review routine documents prepared by junior team members. May provide training and mentorship for junior writers and program managers on document preparation, the use of software for document development, document types, regulatory requirements, and therapeutic area knowledge. • Ensure compliance with quality processes and requirements for assigned documents. Provide input on and independently develops best practices, methods and techniques for achieving optimal results, including various client specific processes. • May assist in program management activities. Identify and resolve out-of-scope activities. Duties could include developing timelines, budgets, forecasts and contract modifications. • Represent the department at project launch meetings, review meetings, and project team meetings.