Clinical Documentation Improvement Specialist Resume Samples

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Clinical Documentation Improvement Specialists help medical staff take better care of their patients by handling and optimizing patient records. Essential job functions seen on a typical resume sample are preparing written reports, advising decision makers, discovering positive and negative patterns in documentation processes, and making suggestions for improvement. Our collection of example resumes for Clinical Documentation Improvement Specialist focuses on skills like recordkeeping, analytical thinking, attention to details, problem solving, teamwork, and knowledge of medical terminology. Eligible candidates hold an Associate's Degree in health information technology.

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1

Clinical Documentation Improvement Specialist- E.r

  • Screened patients according to septic guidelines using real-time electronic surveillance to decrease mortality and report to data entry extractor.
  • Clarified uncertainties and assist clinicians to improve documentation, while patients are still hospitalized and improved CMI within nine months.
  • Implemented physician training on the importance of complete, detailed medical documentation and improved response rate by 70%.
Candidate Info
9
years in
workforce
1
year
at this job
BA
Biological Sciences
MA
Biomedical Science
2

Clinical Documentation Improvement Specialist

Conduct initial and concurrent reviews for each assigned patient and maintained review rate of 90% on assigned cases.

  • Identify and record most appropriate principal diagnosis, secondary diagnosis, complication/comorbidities and procedures to reflect severity of illness and risk of mortality.
  • Communicate with physicians to clarify information, obtain needed documentation, present opportunities and educate for appropriate MS-DRG based on severity of illness.
  • Follow up and collaborate with physicians and appropriate health care team members to resolve documentation issues and ensure accurate and complete documentation in the medical record.
  • Train new team members in Clinical Documentation.
Candidate Info
28
years in
workforce
3
years
at this job
AS
Nursing
BS
Chemistry
3

Clinical Documentation Improvement Specialist

  • Comprehensive review of initial and concurrent inpatient documentation to ensure that severity of illness, utilization of services, and risk of mortality are documented to validate selected DRG's, using 3M coding software.
  • Identification of opportunities for improvement in clinical documentation to validate active diagnoses, and increase SOI and ROM resulting in highest potential hospital reimbursement for services.
  • Responsible for creation of compliant queries to support proper diagnosis and SOI/ROM
  • Responsible for developing and maintaining close working relationship with physicians for resolution of queries to ensure accuracy of documentation.
Candidate Info
4
years in
workforce
7
months
at this job
BS
Psychology
MD
Medicine
4

Clinical Documentation Improvement Specialist

  • Comprehensive data and documentation review to facilitate improvement to the overall quality and completeness of Clinical documentations.
  • Obtaining appropriate and accurate clinical documentation that reflects the severity of illness and risk of mortality for inpatient discharges.
  • Communicates with attending physician either verbally or through written methodology to validate observations and suggest additional and/or more specific documentation as it relates to coding compliance, medical necessity and
  • Adhering to the standards of ethical coding per ICD-10 CM coding guidelines.
  • Querying physicians using the approved query process in order to obtain clinical information.
Candidate Info
5
years in
workforce
1
year
at this job
BS
Integrative Neuroscience
5

Clinical Documentation Improvement Specialist

  • Clinical resource in reviewing medical records in support of consistent documentation for various payer types
  • Identified and reviewed primary and secondary diagnoses and complications to ensure documentation and appropriate capture
  • Submit, monitor, and track verbal and written queries as needed or required
Candidate Info
1
year in
workforce
1
year
at this job
AS
Health Information Management
BS
Nursing
MA
Health Administration
6

Clinical Documentation Improvement Specialist

  • Performs concurrent and retrospective reviews of the medical record for compliance with quality measures
  • Use critical thinking skills to recognize opportunities for documentation improvement
  • Initiates appropriate worksheets and clarifications for inpatients and presents opportunities for improved documentation compliance to medical providers
  • Complete follow-up case reviews in a timely manner
  • Effectively communicate with HIM staff to resolve discrepancies with DRG assignments and coding issues
Candidate Info
15
years in
workforce
8
months
at this job
BS
Nursing
MS
Nursing
7

Clinical Documentation Improvement Specialist

  • Review and analysis of health records to identify relevant diagnoses
  • Able to collaborate extensively with physicians, nurses, other care givers, and medical records coding staff to improve quality and completeness of documentation of care provided and coded. Queries physicians to clarify ambiguous, conflicting, or incomplete documentation.
  • Provides direction for concurrent modification to clinical documentation to ensure appropriate coding for reimbursement for clinical severity and services provided to patients with a DRG-based payer (Medicare/Medicaid).
  • Maintains accurate and complete documentation of clinical information used to measure and report physician and facility outcomes.
  • Provides ongoing education to all members of the patient care team.
Candidate Info
10
years in
workforce
1
year
at this job
BS
Nursing
8

Clinical Documentation Improvement Specialist Supervisor

  • Supervise five Clinical Documentation Specialists
  • Developed Policy's and Procedures for Department
  • Developed, Implemented and now perform quality reviews
  • Prepare Daily Assignments
  • Education of Physicians
  • Concurrent review of inpatient medical records to improve physician documentation. The goal being to accurately capture the primary and secondary diagnoses and procedures during the hospital encounter for accurate portrayal of SOI/ROM.
Candidate Info
25
years in
workforce
9
years
at this job
AS
Nursing
9

Clinical Documentation Improvement Specialist

  • Establish audit plans and conduct retrospective audits of outpatient services to verify records support both reimbursement and medical necessity.
  • Work on multidisciplinary teams related to potentially preventable conditions (hospital acquired) and reimbursement audits impacting the hospital.
  • Perform data analysis of claims to identify trends in reimbursement and/or denials.
  • Work with coding department to improve processes related to provider queries and chart reviews.
  • Concurrent reviews of inpatient visits to ensure documentation reflects severity and acuity.
  • Query physicians to get clarification of patient conditions when the records lack specification.
  • Obtain continued education to maintain knowledge of industry best practices.
  • Developed tip sheets for documentation requirements and perform provider education.
Candidate Info
11
years in
workforce
2
years
at this job
C
Health It
BS
Health Information Management
Acdis Inpatient Coding Bootcamp March 2017
10

RN, Clinical Documentation Improvement Specialist

  • Working knowledge of Medicare Severity-Diagnosis Related Group (MS-DRG) Classification System and ICD10 coding guidelines
  • Comprehension of complex medical and surgical procedures
  • Establish provider trust and credibility with clinically accurate queries
  • Currently reviewing APR DRG Classification System
  • Completed extensive CDI support pilot (2014) to determine extent of CDS financial impact and resource allocation
  • Huron CDI
  • 3M Encoder
  • Centricity EHR ( Electric Health Record)
  • CattailsMD CMR (Combined Medical Record)
Candidate Info
30
years in
workforce
5
years
at this job
HS
Practical Nursing
BS
Nursing

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