Clinical Documentation Specialist
Location
Ohio
Posted
50 days ago
Salary
0
Seniority
Senior
Job Description
Clinical Documentation Specialist
University Hospitals
• Serve as an advisor and expert resource for providers to improve the accuracy of clinical documentation to support patient complexity, risk profiles and appropriate E/M levels • Assist providers in identifying clinically relevant information and capturing the clinical documentation needed to accurately reflect patient acuity • Focus on the recapture and identification of chronic conditions reflected in Hierarchical Condition Categories (HCCs) • Complete pre-visit and post-claim reviews as well as providing clear communication and education to providers on their documentation, coding and billing practices • Coordinate with colleagues from the CDI Program or other members of the organization regarding education and training geared towards improving clinical documentation
Job Requirements
- High School Equivalent / GED (Required)
- Associate's Degree (Preferred)
- 3+ years Coding and/or clinical documentation integrity (Required)
- Extensive clinical knowledge and understanding of pathophysiology (Required proficiency)
- Strong critical thinking skills and utilization of clinical knowledge to identify potential clinical indicators supporting patient acuity and clarifications of the medical record (Required proficiency)
- Excellent written and verbal communication skills (Required proficiency)
- Strong project management skills (Required proficiency)
- Strong interpersonal skills, with demonstrated success at communicating effectively with all levels of the organization (Required proficiency)
- Ability to work independently in a time-oriented environment (Required proficiency)
- Demonstrates skilled ability and comfort with electronic medical records (EPIC preferred) (Required proficiency)
- Proficient with personal computer applications (Excel, Word, and Power Point) (Required proficiency)
- Ability to build education material that is meaningful for providers and team members (Required proficiency)
- Strong problem solving and investigative skills (Required proficiency)
Benefits
- Maintains strict confidentiality of all patients, employee and physician information according to HIPAA guidelines
- Shares in organization’s vision, demonstrates its values, supports its philosophy and is sensitive to its mission.
Related Guides
Related Categories
Related Job Pages
More Medical writer Jobs
Role Description Facilitates clinical documentation improvement through the identification of documentation issues: - Has extensive day-to-day interaction with providers, other patient care givers, coding staff, and Care Coordinators. - Collects and analyzes data and reports. - Develops, coordinates, and/or provides education regarding documentation opportunities. - Reviews the quality of documentation in the patient medical record to enhance quality of care. - Ensures accurate data reporting to regulatory agencies and appropriate reimbursement. - Collaborates with the coding team to promote accurate patient diagnostic and procedural information in the medical record and final DRG assignment. Qualifications - RN with valid Florida license. - 5 years acute care clinical experience OR HIM degree with commensurate CDI experience. - Strong written and oral communication skills. - Computer literacy. - Familiar with MSDRGs, APR DRGs, and coding guidelines. - Understanding of DRG assignment and impact to quality metrics and ratings.
Senior Medical Writer
ICON plcICON is a global healthcare intelligence and clinical research organisation united by a mission to bring new medicines and treatments to patients faster. As a values-driven organisation, integrity, collaboration, agility, and inclusion are at the heart of how we work and interact with each other, customers, patients and suppliers.
Role Description We are currently seeking a Senior Medical Writer to join our diverse and dynamic team. As a Senior Medical Writer at ICON, you will play a pivotal role in leading the development and execution of medical writing strategies for clinical research projects, contributing to the advancement of innovative treatments and therapies. - Leading the preparation, review, and editing of clinical study documents, including clinical study protocols, clinical study reports (CSRs), investigator brochures (IBs), and regulatory submissions, ensuring accuracy, clarity, and compliance with regulatory guidelines and industry standards. - Collaborating closely with cross-functional teams, including clinical research, biostatistics, regulatory affairs, and medical affairs, to interpret and analyze clinical trial data, summarize scientific findings, and communicate key insights in written form. - Participating in the planning and execution of clinical development programs, providing strategic input and scientific expertise to support the design, conduct, and interpretation of clinical studies and research initiatives. - Contributing to the development of publication plans, abstracts, posters, and manuscripts for submission to peer-reviewed journals and presentation at scientific conferences, disseminating study results and scientific insights to the broader scientific community. - Mentoring and coaching junior medical writers, providing guidance on best practices, writing techniques, and scientific principles, and fostering a culture of excellence, collaboration, and continuous learning within the medical writing team. Qualifications - Advanced degree in Life Sciences, Pharmacy, Medicine, or related field, with a minimum of 3-5 years of experience in medical writing within the pharmaceutical, biotechnology, or contract research organization (CRO) industry. - Proficiency in interpreting and summarizing complex clinical trial data, scientific research findings, and statistical analyses, with excellent writing, editing, and proofreading skills, and the ability to communicate scientific concepts to diverse audiences. - Strong understanding of regulatory requirements (e.g., ICH-GCP, FDA, EMA) governing the preparation and submission of clinical documents and publications, and experience in interacting with regulatory agencies during the review and approval process. - Demonstrated ability to work effectively in a fast-paced, deadline-driven environment, managing multiple projects simultaneously and prioritizing tasks based on project timelines and deliverables. - Excellent interpersonal and communication skills, with the ability to collaborate effectively with cross-functional teams, build relationships with key stakeholders, and influence decision-making processes. - 大学卒以上(医薬、獣医、農学、生命科学等の学部学科)、または同等の学位保有者。 - 製薬会社、またはCROにおける5年以上のメディカルライティング業務の経験。 - 主要な当局提出資料の作成にメディカルライターとして関与した経験。 - プロトコール設計から承認申請までのプロセスや、技術的問題を含む臨床開発に関する十分な知識。 - 規制要件、ICHガイドライン、文書作成(CTDを含む)に関する薬事的プロセスについての知識。 - ビジネスレベルの英語力(読み書きスピーキングについて業務遂行プロジェクトリードに支障がないこと)。 Requirements - Employment with ICON is contingent upon having the legal right to work in the country where the role is based. Benefits - Competitive base salary and performance related incentives. - Health and wellbeing programmes including medical, dental, and vision coverage where applicable. - Retirement and pension plans. - Life assurance and disability coverage. - Employee assistance programmes and wellbeing resources. - Learning and development opportunities through structured training and career pathways. - Benefits may vary depending on role and location. Inclusion and Accessibility ICON is an equal opportunity employer. We are committed to building an inclusive and accessible workplace where everyone feels valued and supported. If you require reasonable accommodations during the recruitment process, please let us know or submit a request.
Clinical Documentation Specialist
Sigma SystemsWe are now Hansen Technologies. Follow us @Hansen-Technologies.
• Facilitating improvement in the overall quality and completeness of the medical record documentation • Providing support and expertise through comprehensive assessment and review of inpatient medical records • Ensuring accurate DRG assignment and obtaining appropriate documentation through interaction with physicians, patient caregivers, and health information management coding staff • Monitoring home health patients to ensure they meet CMS criteria for services • Proactive outreach to patients and making recommendations to primary care providers • Facilitating communication and coordinating care with healthcare providers and caregivers • Creating positive relationships with home health agencies as well as primary care clinicians
Role Description As a Registered Nurse (RN) Specialist with CVS Health, you will coordinate care for patients receiving Specialty Medications (most are infused) for chronic disorders in the home. The nurse is responsible for: - Identifying quality home health nursing agencies. - Training on disease and therapy. - Assuring competence of the Home Health nurse prior to providing care to our patients. Hours and Location: - Monday through Friday - 8:00-5:00 either Central, or Eastern Time - This is a work from home position and one can live in any state that is part of the National Licensure Compact (NLC) and within either the Central, or Eastern Time Zone. As a Registered Nurse (RN) you will: - Provide clinical expertise to assess patients, determine homecare clinical needs and coordinate care with qualified Home Health Agencies. - Assess Home Health Agency (HHA) ability to provide appropriate care by determining clinical infusion and home care expertise. - Educate and approve agencies to provide care upon determining competency. - Provide disease, medication, and home infusion therapy education to qualified home care professionals. - Complete clinical input into multiple data systems to include clinical status, HHA information and demographics. - Work with pharmacy team members to assure a seamless process regarding timely medication shipments, supply inventories, site of care, and safe medication practices. - Manage a caseload of therapy-specific patients and identify any issues that may affect the prescribed treatment plan. - Obtain Nursing Benefit Verification and communicate payer coverage for nursing visits to patients. - Work with Licensure team to manage/maintain licensing requirements across multi-states. - Perform other duties as assigned. Registered Nurses (RNs) Specialist with CVS/specialty infusion services have a uniquely rewarding setting to use their exceptional nursing skills. As a national leader in the home infusion field and a Fortune 5 company, we seek those special RNs who not only possess strong clinical expertise with innovative ideas but the kind of deep compassion and sensitivity it takes to treat people in their homes. Qualifications - Registered Nurse living in a state that is part of the National Licensure Compact (NLC) and possessing that state's compact license. - Must also have the ability to become licensed in all 50 states. - 5+ years of recent clinical nursing experience. - 2+ years of experience in either home infusion, or infusion clinic working with specialty medications. - Knowledge of and experience with infusion therapy supplies and pumps. - Excellent customer service approach in verbal and written communication. - Demonstrated problem resolution experience. - Strong organizational and computer skills, especially with MS Office applications. - Ability to multi-task, work with multiple monitors and pharmacy systems. Requirements - RN Diploma, Associates or B.S. degree in nursing. Benefits - Comprehensive benefits package designed to support the physical, emotional, and financial well-being of colleagues and their families. - Medical, dental, and vision coverage. - Paid time off. - Retirement savings options. - Wellness programs and other resources, based on eligibility.


