Clinical Documentation Specialist Resume Samples

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Clinical Documentation Specialists provide support to medical staff by analyzing medical information. Usual duties listed on a Clinical Documentation Specialist example resume are collecting data, writing reports, identifying health care issues, updating databases, finding areas that can be improved, and presenting findings to medical staff. The ideal candidate should showcase in his or her resume knowledge of medical terminology, effective communication, computer competences, accuracy, analytical thinking, and problem-solving orientation. Most candidates for this job hold an Associate’s Degree in health information technology.

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1

Clinical Documentation Specialist

  • Generated positive financial impact by my activities of over 2 Mil in 5 years.
  • Increased accuracy of documentation resulting in a yearly increase in the Medicare blended rate.
  • Increased the reimbursement on 25% of the charts reviewed, facilitating accurate MD documentation resulting in a DRG (final diagnosis) change.
  • Review patient medical records to ensure accuracy of physician documentation as compared to the Medicare approved verbiage.
  • Increase the accuracy of documentation and capture co-morbid conditions to more correctly reflect the mortality index of the facility.
  • Instituted and implemented a WIKI to improve timely communication between staff on multiple units and serve as an information repository.
Candidate Info
21
years in
workforce
5
years
at this job
AS
Nursing
BS
Information Technology
2

Clinical Documentation Specialist

Promoted appropriate clinical documentation through interaction with physicians, nursing staff, and HIM staff.

  • Facilitated improvement in the overall quality and completeness of medical record documentation through the query process along with formal and informal education.
  • Impacted financial reimbursement through improved quality of clinical documentation.
  • Reviewed medical records for identified payer populations (for example Medicare, Medicaid, Blue Cross Blue Shield) as directed on admission and throughout hospitalization.
  • Worked with Physician Advisor to improve Physician response to queries.
  • Documented reviews in EPIC system to ensure accurate reporting.
Candidate Info
2
years in
workforce
HS
Nursing
C
Health Informatics
BS
Behavioral Science
3

Clinical Documentation Specialist

Ensures that quality indicators of severity of illness and risk of mortality are accurately reflected per documentation in the medical record

  • Collaborates with staff, coders and physicians to identify and reflect the quality and acuity of administered care
  • Responsible for accuracy of concurrent inpatient coding process and DRG assignment
  • Successfully completed 30hr course-maintains Cerfication in ICD-10-CMS/PCS Hospital coding-"Certified to Code"
Candidate Info
24
years in
workforce
7
years
at this job
BS
Nursing
4

Clinical Documentation Specialist

After receiving a promotion to RAC Compliance Coordinator, responsibilities were kept as Clinical Documentation Specialist as time allowed.

  • Reviewed and coded inpatient charts for purpose of querying physicians concurrently and IDOC for clarification of documentation of diagnoses, POA.
  • A goal was to have accurate diagnoses reflect the severity of the patient's condition, which helped to provide appropriate reimbursement.
  • Completed training through J.A. Thomas and Associates, and maintained continuing education seminars.
  • Documented and tracked in JATA computer software, 3M coding software, Cerner, MIDAS.
  • Wrote coding appeal letters.
  • Co-managed Clinical Documentation Department after manager left.
  • RAC lead-until promoted to RAC Coordinator, presented RAC updates during RAC Committee and Revenue Cycle.
  • Explained to physicians, residents and Nurse Practitioners about the importance of accurate documentation of diagnoses. Presented to physician groups.
  • Presented Power Point presentations to senior leadership regarding coding changes and documentation challenges.
  • Alerted risk management if Hospital Acquired Conditions were identified.
Candidate Info
17
years in
workforce
3
years
at this job
BS
Nursing
Program
5

Clinical Documentation Specialist

Facilitated improvement in the overall quality, completeness, and accuracy of medical record documentation by performing prospective chart audits

  • Extensive interaction with physicians to ensure the clinical documentation reflected the severity of illness and level of services rendered to patients
  • Provided ongoing education of physicians and coding staff
  • Analyzed aggregated data to identify patterns and areas of focus for documentation and coding improvement initiatives/education
  • Participated in redetermination, reconsideration, and appeals process upon requests, related to recovery audits (RAC) and DRG validation
Candidate Info
15
years in
workforce
1
year
at this job
HS
High School Diploma
HS
Nursing Assistant
AA
Business Administration
6

Team Coordinator, Clinical Documentation Specialist

Increased hospital's case mix index equal to $1.4M in bottom line reimbursement in my first year

  • Developed a communication tool between the coders, DRG validator and clinical staff to promote learning and maximize reimbursement
  • Trained 2 brand new RN-CDI's
  • Participate on hospital teams: Utilization Review, CME, Core Measures and Leadership Council
  • Suggested a hospital wide recycling program which came to fruition with a $7K yearly hospital savings in trash collection
Candidate Info
33
years in
workforce
6
years
at this job
BS
Nursing
7

Team Lead Clinical Documentation Specialist

Developed new program for Compliant Documentation Improvement program (CDMP) at PHP in relation to THR's organizational strategy, vision and initiatives

  • Planned CDMP rollout, established timeline, and developed policies and procedure for new department
  • Solved IT issues and ordered appropriate tools needed for the Clinical Documentation Specialists
  • Proficient in Healthcare Coding utilizing tools such as 3M and JATA software
  • Supervised two Clinical Documentation Improvement departments, Texas Health Allen and Texas Health Plano
Candidate Info
34
years in
workforce
8
years
at this job
AS
Nursing
BS
Nursing
MS
Nursing
8

Registered Nurse, Clinical Documentation Specialist

Helped to build first CDI program at the facility

  • Performed concurrent/retrospective reviews of medical records, established a working MS-DRG, evaluated SOI/ROM, supported core measures and other quality reporting measures
  • Worked with the CHW Midas team to develop and pilot parts of the CDI module and reports
  • Partnered with the Registered Dietitians to identify at-risk patients for nutritional deficiencies and skin breakdown
  • Presented monthly pressure ulcer data to the hospital president at HAPU Committee meeting
  • Volunteered at the monthly Wound Care Committee meetings to discuss needed nursing documentation of wounds, skin breakdown, and POA indicators
Candidate Info
7
years in
workforce
2
years
at this job
AS
Nursing
Nursing
Statistics
9

Clinical Documentation Specialist & Coding Supervisor

Conduct clinical reviews of outpatient office visit records to evaluate the clinical documentation for services provided.

  • Facilitate ongoing achievement of the clinic's goals.
  • Consistently meet established productivity targets for record review and also successful consecutive attestations for EHR incentive program.
  • Applied working knowledge of Health Information Management Standards of coding to ongoing evaluation of medical record documentation.
  • Implement strategies for sustained work process changes that facilitate complete, accurate clinical documentation.
  • Facilitated multidisciplinary team in efforts for clinical documentation improvement.
  • Worked independently with minimum direction, anticipate and organize workflow, prioritize and follow through on responsibilities
Candidate Info
24
years in
workforce
4
years
at this job
BS
Medicine & Bachelor Of Surgery
Medical Billing & Coding
Anesthesiology
10

Electronic Clinical Documentation Specialist

  • Selected to lead an interdisciplinary group of Occupational, Physical, Speech Language Therapists in the design, content, workflow, training, and implementation of documentation for organization's newly acquired Electronic Health Record-Cerner Corporation
  • Collaborated with Cerner in design, build, testing, and implementation of new PT/OT/SLP and other modules
  • Ensured regulatory compliance of documentation to demonstrate skilled service, meet standards, and increase revenue
  • Served as Clinical Sales Lead and Subject Matter Expert of rehabilitation content to external rehabilitation providers delivering high end presentations, demonstrations, and round table discussions with C-Suite and other operational managers
  • Exceeded sales goals year over year resulting in over 60 new contracts yielding several million dollars in revenue for both Cerner Corporation and RIC
Candidate Info
18
years in
workforce
7
years
at this job
BS
Occupational Therapy
MS
Health Administration
Membership

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