Clinical Documentation Specialist Resume Samples - Page 2

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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.

For more information on what it takes to be a Clinical Documentation Specialist, check out our complete Clinical Documentation Specialist Job Description.

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11

Clinical Documentation Specialist

Resolve or clarify diagnoses with conflicting, missing, or unclear information by consulting with doctors or others or by participating in the coding team's regular meetings.

  • Was instrumental in positive reimbursement shifts in 48 charts in one month
  • Maintained accurate, detailed reports and records
  • Utilized knowledge of hospital operations, units, coding systems and medical staff physicians to detect clinical documentation problems
  • Trained physicians in ICD-9 coding of SIRS & PNA as PDx for best reimbursement
Candidate Info
7
years in
workforce
1
year
at this job
BS
Nursing
12

CLINICAL DOCUMENTATION SPECIALIST (cds)

Concurrent Coding based on ICD-9

  • Has worked in multiple specialty to include General Surgery, Internal Medicine, Psychiatry, Oncology
  • Standard cases reviewed 15-20cases/day; but has viewed as many as 20-30 cases/day
  • Oversaw cases at two separate sites
  • Audited charts and improved documentation
  • Composed queries as required
  • Interacted and contributed to Case Management meetings as CDI Specialist
  • Provided Intequal and Milliman Admission criteria as required
Candidate Info
17
years in
workforce
2
years
at this job
MD
Medicine
MD
Internal Medicine
13

Qa Clinical Documentation Specialist Iii

Managed day to day activities of the Data Review Team (DRT), program data bases to ensure completion and accuracy

  • Lead, facilitate and support teams improving processes involved in the design and execution of clinical trials, up to and through implementation
  • Ensure identification, communication and adoption of best practices in clinical trials and submissions
  • Participated in cross-functional continuous Clinical Development functions improvement
  • Interacted with cross-functional components of Clinical Study Teams supporting in delivering data from major reporting events according to established goals
  • Supported compliance with SOP's
Candidate Info
7
years in
workforce
5
years
at this job
BS
Healthcare Administration
MA
Master of Arts
14

Clinical Documentation Specialist Supervisor

Collaborated with utilization managers, nursing staff, and other ancillary staff regarding interaction with physicians on documentation improvement.

  • Assisted coders with concurrent review of inpatient medical records and discussed documentation opportunities with physicians.
  • Collaborated with coders and case managers, reviewing inpatient medical records to ensure correct Diagnosis-Related Group (DRG) assignment.
  • Monitored and evaluated effectiveness of chart reviews and query outcomes. Performed monthly closed chart reviews.
  • Communicated with individual physicians and medical staff departments to facilitate complete and accurate documentation.
Candidate Info
23
years in
workforce
3
years
at this job
BS
Nursing
MBA
Health Care Management
15

Clinical Documentation Specialist

Monitored patient charts to ensure physician's documentation mirrored patient acuity.

  • Interacted with case managers to identify additional diagnosis that justified LOS.
  • Collaborated with physicians, nurse practitioner, and physicians' assistants in response to changes in patient acuity.
  • Administered education to physicians, nurse practitioners, and physicians' assistants in regards RAC Auditors.
  • Queried physicians for documentation clarification when admitting diagnosis appeared ambiguous.
  • Helped coders identify secondary diagnosis that increase case mix index and relative weight.
Candidate Info
25
years in
workforce
2
years
at this job
AA
Nursing
BS
Respiratory Therapy
16

Clinical Documentation Specialist

Perform daily chart audits for multiple providers to ensure that documentation is accurate and correct per Medicare standards

  • Instructed multiple physicians on Risk Adjustment and Coding Guidelines
  • Responsible for conducting education for assigned providers and administrative staff within the providers organization on Risk Adjustment, ICD 9 codes, HCC methodology, HEDIS/Quality Measures (chief operational initiatives), and STARS measures.
  • Assist PCP with proving cost effective care for Medicare Advantage members
  • Case Managed around 3,000 Medicare Advantage patients for multiple physicians
  • Case Managed patients to help decrease post hospital re-admissions
Candidate Info
23
years in
workforce
4
years
at this job
AS
Applied Science
BS
Psychology
17

Clinical Documentation Specialist

  • Completed concurrent documentation review to facilitate appropriate DRG assignment
  • Interacted effectively with physicians regarding documentation appropriate to diagnosis and severity of illness
  • Ensured clinical issues are reviewed with coding staff to assign an appropriate final DRG
  • Developed and monitored metrics to assess impact of and performance opportunities for Clinical Documentation initiatives. Presented metrics with analysis and recommendations to Supervisor.
Candidate Info
9
years in
workforce
3
years
at this job
HS
High School Diploma
AS
Associate of Science
18

Clinical Documentation Specialist

Perform concurrent review of medical records for identified payer populations like Medicare, Medical and private prayers

  • Promoted accurate documentation of medical necessity including appropriate admission status, severity of illness, proper MS -DRG assignment, financial reimbursement, case mix indexing and daily census.
  • Educate and communicate with physicians and other staff as needed to foster collaborative working relationships
  • Perform follow-up reviews to ensure issues needing clarification have been documented and communicate with CNO & CEO on monthly basis.
  • Work closely with Professional coders to assure documentation of discharge diagnoses and any co-existing co-morbidities to accurately reflect patient's clinical status
Candidate Info
8
years in
workforce
2
years
at this job
MA
Business Administration
MA
Public Health
19

Clinical Documentation Specialist

Ensured the accuracy of provider chart dictation for billing of services according to the CDIP guidelines.

  • Assigned accurate codes for diagnoses, treatments, and procedures according to the appropriate classification system for outpatient encounters.
  • Utilized technical coding principals to assign appropriate ICD-9-CM diagnoses.
  • Coordinated clinical documentation improvement opportunities for medical staff and allied health professionals.
  • Rectified pre-bill coding related edits and coded related denials.
  • Informed providers of policy and regulation changes and any updates to the billing charge tickets.
Candidate Info
17
years in
workforce
2
years
at this job
C
Negotiation Skills, Conflict Resolution And Employee
AS
Health Information Technology
BS
Management Information Systems
20

Clinical Documentation Specialist

Worked as part of case management performing chart reviews for coding and reimbursement purposes:

  • Collaborated with coding specialists to ensure proper coding and billing for Medicare
  • Collaborated with physicians to ensure proper documentation needs for correct coding and billing needs
  • Performed teaching seminars for nursing, physician and coding staff to bring new documentation and coding needs to light according to ICD-9 and ICD-10 reimbursement policies
Candidate Info
9
years in
workforce
1
year
at this job
BS
Nursing

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