BJC HealthCare is one of the largest healthcare organizations in the U.S. focused on delivering "the world's best medicine," made better by its 30,000+ clinical
Documentation Specialist
Location
United States
Posted
20 hours ago
Salary
0
Seniority
Mid Level
No structured requirement data.
Job Description
Documentation Specialist
BJC HealthCare
Role Description Identifies documentation problem areas and creates audits directed at monitoring performance improvement in these areas. Obtain pre-certification for clinical areas and any home care needs. Provides assistance with pre-certification for inpatients that require testing as outpatients. Responsibilities - Studies existing agency policies and interviews agency personnel to evaluate effectiveness of quality improvement programs. - Facilitates all policies and procedures applicable to documentation process. - Develops educational materials to educate team members. - Compiles statistical data and creates reports summarizing audit findings as requested. - Coordinate initiation of authorization for testing for inpatients and obtain authorization for transport services for patients being transferred to another facility or home. Qualifications - High School Diploma or GED - Associate's Degree (preferred) - Licensed Practical Nurse (preferred) - RN (preferred) Requirements - Experience: Less than 2 years - Supervisor Experience: No Experience Benefits - Comprehensive medical, dental, vision, life insurance, and legal services available first day of the month after hire date - Disability insurance paid for by BJC - Annual 4% BJC Automatic Retirement Contribution - 401(k) plan with BJC match - Tuition Assistance available on first day - BJC Institute for Learning and Development - Health Care and Dependent Care Flexible Spending Accounts - Paid Time Off benefit combines vacation, sick days, holidays and personal time - Adoption assistance
Related Guides
Related Categories
Related Job Pages
More Medical writer Jobs
Clinical Documentation Specialist, Audit Coordinator
Trinity HealthWe are one of the largest not-for-profit, faith-based health care systems in the nation.
• Provides onsite and remote clinical documentation integrity (CDI) support to the Health Ministry (HM) CDI programs as part of the System Office CDI Float Pool. • Utilizes advanced coding and/or clinical expertise to direct efforts toward the improvement and integrity of clinical documentation. • Responsible for reviewing and/or auditing medical record clinical documentation to support the medical necessity, severity of illness, risk of mortality, accurate coding, clinical evidence, resources consumed, and level of services rendered to all patients. • Audits HM CDSs for query compliance, workflow and missed documentation opportunities. • Trains end users in the use of CDI system software, standards, and workflow. • Demonstrates understanding of and facilitates appropriate clinical documentation to ensure that the medical necessity, severity of illness, risk of mortality, accurate coding, clinical evidence, resources consumed, and level of services provided are accurately reflected in the health record. • Conducts clinical documentation chart reviews and queries providers as appropriate to support RHMs staffing needs. • Reviews may be conducted on site or remotely. • Follows HM CDI Program workflow and processes and communicates with local CDI Team to support local operations. • Communicates with physicians and other members of the healthcare team at the HM regarding clinical documentation as part of local CDI Team assignment. • Audits medical records, queries, CDS and coder assigned codes, CDI software entries, etc., as requested to provide feedback to the HMs for improvement opportunities. • Trains end users in the use of CDI system software, standards, and workflow. • Provides documentation education to providers and members of healthcare team at the RHM as part of CDI Team assignment or as requested. • Demonstrates ability to quickly learn and master the various CDI technology applications, systems and workflows in place across the enterprise. • Provides expertise in problem-solving skills based on theoretical knowledge, clinical experience and sound judgment and serves as a professional role model by demonstrating desirable practice behaviors. • Assists the System Office Clinical Documentation Manager with all aspects of the CDI program across the system including data collection and maintenance of the CDI Dashboard. • May develop educational content for providers and CDSs on CDI workflow and processes, CDI and Physician software systems, and documentation and coding guidelines as requested. • Performs other duties as assigned by leadership.
• Implements and continuously develops onboarding for all new Clinical Documentation Specialists (CDSs) for mentoring and education needs. • Leads and coordinates training of new CDI staff. • Collaborate with CDI leadership and other clinicians to facilitate the ongoing relevance of department specific orientation content, educational materials, and training programs/resources. • Formulates customized education to other healthcare professionals based on audience and areas of opportunity. • Audits CDSs as needed to ensure that system objectives are met. • Provides 1:1 mentoring as needed. • Oversees and coordinates SMART related education, meetings, and requirements for the department and as instructed by the SMART department.
Clinical Documentation Specialist – CDI
SolventumEnabling better, smarter, safer healthcare to improve lives.
• Review inpatient medical records for documentation accuracy, completeness, and compliance • Maintain an accuracy rate of 98% • Identify opportunities for clarification of diagnoses and procedures • Initiate compliant physician queries to clarify conflicting documentation • Collaborate with coding staff to ensure accurate coding and DRG assignment • Monitor documentation trends related to mortality and quality indicators • Conduct clinical validation reviews for high-risk conditions • Maintain productivity and quality standards • Participate in multidisciplinary rounds and documentation improvement initiatives
Medical Writer
Inizio MedicalInizio Medical is part of Inizio, a global healthcare consulting and communications group that supports some of the world's leading life sciences companies by providing a full suite of advisory, medical, marketing, communications, and patient and partner engagement services. We are a team of 10,000+ experts working together in 35 countries to create something extraordinary. We exist to solve health challenges and develop transformational ideas that positively impact human lives. At Inizio Medical, we are committed to driving a culture of diversity, inclusion and belonging where everyone can bring each facet of themselves to work each day.
Role Description Inizio Medical has built a large team of medical writers in South Africa, becoming the leading medical communications company in Africa. We are recruiting for a new intake of medical writers who will start with us in July 2026. Our teams in South Africa work alongside our global teams (based in the US, UK, South Africa and EU) in our three med comms agencies: ApotheCom, Nucleus Global and Ashfield MedComms. This will give you the opportunity to work on cutting edge science with world-leading experts in a variety of therapy areas, and help to deliver impactful results for the healthcare community. To give you the best start in your med comms career, you will receive industry-leading, award-winning training through our allegro.WRITE training programme. During your first six weeks with the company, a dedicated team of experts will provide training and individual mentoring focused on developing: - Writing skills - Project management - Teamwork - Networking Combining complex scientific understanding with creativity, Inizio Medical develops impactful medical affairs strategies and compelling communications. Underpinned by world-class medical analytics capabilities and applied AI tools, Inizio Medical redefines the role of medical affairs in drug development and commercialization. Principal Role: - Researching and developing technical medical material - Ensuring that all outputs adhere to the written brief, are accurate in content and editorial style, and can be referenced - Liaising with clients and medical experts on content development - Attending scientific and client meetings where output is required Qualifications - An advanced degree in a biomedical subject Requirements - Excellent written and verbal communication skills - Demonstrate excellent and versatile scientific writing and editing ability - Experience of writing scientific publications and conference presentations - Ability to generate materials to a high standard and quality, with minimal internal review/assistance - Excellent project-management and organisational skills - Flexibility, adaptability and resourcefulness - Good time management skills - Judgment and problem-solving - Excellent quality control skills and meticulous eye for detail – style/consistency, grammar, scientific accuracy, proof-reading, layout, etc. - Ability to ensure all writing meets the client’s strategic marketing objectives, as well as being of high scientific quality/credibility - Understanding of pharmaceutical and health-related issues - Strong sense of responsibility and urgency; ability to take ownership of projects - Ability to work independently under limited supervision - Solid understanding of human pathophysiology and disease; ability to learn new and diverse subject areas quickly - Ability to work within a team and form productive working relationships within, and external to, Huntsworth Health - Strong client-centric attitude - ability to work with clients on projects, ensuring they meet strategic marketing and medical needs - Flexibility and ability to manage simultaneous priorities, changing deadlines, and limited resources - IT skills – Word, PowerPoint, internet searching Benefits - The company will provide all the necessary equipment to perform the role (including laptop, headset, keyboard, mouse and stipend towards data package) - Inclusivity is key to us; if you require any reasonable adjustments due to disabilities or other needs during the recruitment process, please inform us



