Clinical Documentation Improvement Specialist
Location
United States
Posted
5 days ago
Salary
0
Seniority
Senior
Job Description
Clinical Documentation Improvement Specialist
InnovaCare Health
• Review patient medical records (charts) for completeness, accuracy, and compliance with ICD-10-CM coding guidelines and CMS risk adjustment criteria. • Identify documentation gaps or opportunities that impact HCC capture and risk scores. • Utilize AI-enabled CDI platforms, electronic health records (EHR), and data dashboards to analyze trends, prioritize chart reviews, and flag discrepancies. • Work closely with primary care providers, specialists, and other clinical staff to clarify documentation and educate on best practices, when required. • Collaborate with coding, billing, compliance, and analytics teams to align goals and implement CDI strategies, when required. • Support the execution of cross-functional projects aimed at improving data integrity, documentation quality, and risk adjustment outcomes. • Maintain accurate tracking and reporting of CDI queries, provider responses, and documentation improvements in designated systems or databases. • Stay up to date on current CMS guidelines, ICD-10-CM updates, HCC risk adjustment models (CMS-HCC, RxHCC), and relevant healthcare regulations.
Job Requirements
- Credentialed coder (CRC, CPC, CMPA or similar).
- Clinical background is a plus (RN, IMG).
- Minimum of 3 years of experience in clinical documentation improvement, risk adjustment, or outpatient medical coding.
- Strong understanding of ICD-10-CM coding, HCC coding principles, V28 risk model and Medicare Advantage documentation requirements.
- Experience working with AI-based CDI platforms, EHR systems, and healthcare data tools.
- Excellent communication, critical thinking, and problem-solving skills.
- Ability to work independently and collaboratively in a fast-paced environment.
- Bilingual (English/Spanish) is a plus.
Benefits
- InnovaCare participates in E-Verify
Related Guides
Related Categories
Related Job Pages
More Medical writer Jobs
• Develop and write high-quality scientific and medical content, including congress abstracts, posters, presentations, and peer-reviewed original research articles. • Translate complex scientific data into clear, compelling communications tailored to diverse audiences. • Collaborate with cross-functional teams on publication development, including internal teams and external collaborators. • Support end-to-end publication processes, including planning, drafting, submission, peer review responses, and resubmissions. • Oversee and manage the publication planning and execution process, including alignment with evidence generation strategies, resourcing, and timeline management. • Ensure all publications adhere to company guidelines, regulatory requirements, and best practices in medical writing (e.g. ICMJE and GPP best-practice guidelines). • Oversee publication review and approval process, including tracking and documentation systems. • Develop, refine, and implement SOPs and best practices for publication development and medical writing.
Medical Writer
MERGEWe merge storytelling with technology to promote health, wealth and happiness in the world.
• Be responsible for effectively developing scientific/clinical content, in collaboration with or under the guidance of a Medical Director • Collaborate with medical and copy teams to research, write, and edit content in distinct therapeutic categories, ensuring scientific validity and clinical applicability • Content development: sales aids, whitepapers, slide kits, case studies, conference reports, video scripts, website content, mechanism of action materials, reprint carriers, and patient education materials • Cultivate expertise in assigned therapeutic areas • Research and secure references to ensure the accuracy of medical/scientific statements and brand claims • Work with scientific content associate to annotate content to ensure all deliverables are fully cited and supported by reliable sources • Work with art directors to ensure data visualization is accurate and effective • Attend review committee meetings, support clients in resolving issues; ensure executed copy updates address review committee requirements • Interact with clients on issues related to scientific content and project deadlines under the direction of account management and the medical director • Inform account management of potential barriers to successful project completion
Clinical Trial Transparency Associate
ICON plcICON plc, or simply ICON, is a global provider of outsourced development services to companies in industries like biotechnology, medical devices, and pharmaceuticals. Headquartered
Role Description As a Clinical Trial Transparency Associate at ICON, you will be responsible for processing the anonymization of clinical trial documents and datasets required for public disclosure. The Anonymization Specialist will partner with internal and external collaborators on the planning, initiation, and delivery of anonymized documents and datasets in support of the EU Clinical Trial Regulation (EU CTR), ClinicalTrials.gov, and Publications and Regulatory Authority Transparency Submissions (e.g., EMA Policy 0070, Health Canada PRCI), manuscript publications, and data sharing. - Manage and facilitate anonymization of datasets and documents against planned timelines, in accordance with Incyte SOPs and regulatory requirements. - Assess documents in-scope for public disclosure according to EMA Policy 0070 and Health Canada PRCI. - Work closely with Biostatistics and Programming groups and Medical Writing teams to identify and assimilate the required documents and datasets. - Develop anonymization plans based on direct and indirect identifiers by measuring and mitigating re-identification risk according to GDPR guidance. - Process datasets and documents and apply required transformations. - Contribute to Anonymization Reports to support anonymization packages for policies of Health Canada and EMA. - Ensure accurate and consistent redaction of clinical trial documents to support EU CTR, ClinicalTrials.gov, and Publications. - Quality check of documents redacted/anonymized by other team members. - Collaborate with Regulatory Operations to ensure the publishing of redacted documents in the Regulatory Document Management System. - Experience with the use of Technology Tools for delivery of Anonymized Clinical Documents. Qualifications - Bachelor’s degree in a scientific or technical field. - Experience with documents anonymization and clinical trial transparency. - Minimum 3 years of work experience in either the health sciences or related industries (pharmaceutical, CRO, etc.). - Working knowledge of the global regulatory guidelines pertaining to clinical trial disclosure and transparency. - Demonstrated experience in global clinical trial disclosure and transparency processes and systems. - Demonstrated Excel and analytical skills, working knowledge of SharePoint and/or document management systems. - Strong communication, organizational, time management, and project management skills. - Knowledge of ICH-GCP, awareness of clinical publication practices and standards (ie, ICMJE). Benefits - Various annual leave entitlements. - A range of health insurance offerings to suit you and your family’s needs. - Competitive retirement planning offerings to maximize savings and plan with confidence for the years ahead. - Global Employee Assistance Programme, TELUS Health, offering 24-hour access to a global network of over 80,000 independent specialised professionals who are there to support you and your family’s well-being. - Life assurance. - Flexible country-specific optional benefits, including childcare vouchers, bike purchase schemes, discounted gym memberships, subsidised travel passes, health assessments, among others.
• leading the development of high-quality and on-time clinical study documents • planning, writing, editing, formatting, and QC review of clinical documents including clinical study protocols, IBs, ICF templates, DSURs, CSRs • ensures smooth and effective document management in collaboration with Sponsor, external vendors, and/or internal project teams • independently formulate key messages from clinical study data • author complex content using knowledge/skills and understanding of processes • communicate clearly and concisely both in writing and verbally with internal and client teams • contribute to the development and maintenance of medical writing processes, SOPs, templates, and work instructions




