Role Description Involves the evaluation of physician documentation, utilizing clinical expertise to ensure that the patient’s severity of illness and risk of mortality are accurately portrayed in the medical record for specificity and increased coding accuracy. Interacts with physicians, clinical staff, and health information management professionals. Works with coding staff to ensure that documentation of discharge diagnoses and any co-existing co-morbidities are a complete reflection of the patient’s clinical status and care. Qualifications - Clinical expertise in evaluating physician documentation. - Ability to interact effectively with physicians and clinical staff. - Experience in health information management. - Knowledge of coding practices related to discharge diagnoses and co-morbidities. Requirements - Reports to a CDI Manager under the leadership of the System Director of CDI. - Supports best practices in clinical documentation integrity strategies. - Emphasis on severity of illness, medical complexity, and quality in the medical record. - Follows Case Mix Index (CMI), risk-adjusted outcomes, and mortality ratings. Benefits - Comprehensive benefits package. - Equity in care delivery and workforce. - Commitment to building a diverse community. - Supportive and welcoming culture. Company Description The University of California, San Francisco (UCSF) is a leading university dedicated to promoting health worldwide through advanced biomedical research, graduate-level education in the life sciences and health professions, and excellence in patient care. It is the only campus in the 10-campus UC system dedicated exclusively to the health sciences. We bring together the world’s leading experts in nearly every area of health. We are home to five Nobel laureates who have advanced the understanding of cancer, neurodegenerative diseases, aging, and stem cells.

Role Description Facilitate clarification to clinical documentation in the medical record through extensive concurrent reviews with interactions with physicians, nursing staff, other interdisciplinary team caregivers, and health information management coding staff. This supports appropriate acuity, resource utilization, quality, severity of illness/risk of mortality (SOI/ROM), and reimbursement. Ensures that clinical severity captured for the level of service rendered to all patients with a DRG based Payor (i.e., Medicare, Medicaid, Commercial, etc.) is accurate. Supports timely, accurate, and completed documentation of clinical information used for measuring and reporting physician and medical center outcomes. On an ongoing basis, CDS will provide educational requirements on clinical documentation to all members of the interdisciplinary care team while ensuring compliance with regulatory guidelines is maintained. Qualifications - Associate’s degree in Nursing required - Bachelor's degree in Nursing preferred - Medical/Osteopathic Doctorate (MD/OD) or an internationally qualified physician (IMD/MBBS) preferred - Nurse candidates must have current Registered Nurse licensure in North Carolina or compact/multi-state license required - Nursing candidates must have 5 years of clinical experience in an inpatient hospital setting - 1 year of critical care experience (ED, ICU, etc.) required - Medical/Osteopathic Doctorate (MD/OD) candidates working towards their degree must have 4 years of inpatient hospital setting experience required - 2 years of ICD-10 CDIS experience required Requirements - Proficiency in reading, writing, and speaking the English language - Excellent observation skills - Critical analytical thinking, problem-solving skills - Verbal and written communication skills - Basic knowledge of computers, Microsoft Windows software products, and keyboarding skills - Ability to communicate with people from various professions and backgrounds with tact and diplomacy - Ability to remain calm in stressful situations - Knowledge of DRG Payor issues, documentation opportunities, and clinical documentation requirements - Flexible with changing workload/assignments - Demonstrate positive teamwork/interpersonal relations with all members of teams (coworkers, supervisors, physicians, nurses, etc.) - Ability to work with highly sensitive information and materials where confidentiality is of the utmost importance - Remote CDS workers must have and maintain secure space and internet connection Benefits - Some light carrying, lifting may be required - Occasional walking required to access all areas of the medical center - Near visual acuity to proofread hand or typewritten materials - Reaching, handling, and use of fingers to operate office machinery - Position may involve skin, eye, mucous membrane, or parenteral contact with blood or other potentially infectious materials - Must be able to lift 35 pounds Required Licenses and Certifications - RN - Board Of Nursing Cape Fear Valley Health System is an Equal Opportunity Employer M/F/Disability/Veteran/Sexual Orientation/Gender Identity.

• Research, write, and revise high-quality, original editorial content • Ensure scientific accuracy while editing and referencing • Liaise with clients, authors and colleagues to progress projects effectively • Attend congresses, symposia and advisory board meetings as required and liaising with speakers and clients • Provide input on project specifications, costings and schedules, working with the internal account team to ensure projects are delivered to time and budget • Provide good briefings to colleagues and freelancers • Actively participate in account development meetings to grow repeat business • Mentor new writers

• The Senior Medical Writer is responsible for the development of medical writing deliverables that support the clinical regulatory writing portfolio • Preparing/Updating/Merging RMPs/Company Core-RMPs (CC-RMPs) • Managing scheduled and unscheduled aggregate reports including but not limited to Periodic Safety Update Reports (PSURs) • Conducting critical appraisal and systematic review of literature with a focus on background epidemiology • Performing aggregate report compliance activities including quality review • Coordinates and liaises with the members of Study Management Team (SMT) • Prepares clear and accurate narratives based on Clinical Database and Safety Database outputs provided by the client • Responsible for the end-to-end signal management process