Clinical Documentation Specialist Resume Samples - Page 3

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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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21

Clinical Documentation Specialist

Performed care delivery documentation system and related medical records documents.

  • Worked closely with the medical staff to facilitate appropriate clinical documentation of services provided.
  • Performed independently in a time-oriented environment.
  • Conducted clinically based concurrent and retrospective reviews of inpatients medical records to evaluate the clinical documentation for reflective quality of care outcomes and reimbursement compliance for acute care services provided.
Candidate Info
13
years in
workforce
1
month
at this job
MA
Management
MD
Doctor of Medicine
Anesthesiology
22

Clinical Documentation Specialist

  • Collaborated with healthcare providers to improve the quality and completeness of documentation for the care provided
  • Appropriate DRG assignment and procedures to reflect and support severity of illness and risk of mortality
  • Team leader for [company name] over a team of 8 CDS, acted as preceptor for new CDI staff, organization of daily assignments, and adjustments of coverage as needed driven by census
Candidate Info
11
years in
workforce
5
years
at this job
23

Clinical Documentation Specialist

Concurrent chart review for acuity/specificity of disease processes for inpatient admissions hospital wide

  • Provide physician/staff education on the importance of accurate/specific clinical documentation
  • Responsible for hard copy/TDS and/or verbal physician queries on patient disease processes/acuities/severities in order to provide clinical accuracy for acuity/hospital reimbursement purpose
  • Work closely with case management and all medical staff in order to ensure accuracy of clinical documentation/decrease in length of stay/quality/core measures
  • Medicare reporting of all Restraint Deaths for accuracy and clinical necessity
  • Clinical Liaison between Physicians and Health Information Management Staff
  • Provide physician education on upcoming ICD-10 implementation for October 2014
Candidate Info
12
years in
workforce
3
years
at this job
BS
Bachelor of Science
24

Clinical Documentation Specialist

Responsible for medical record review to insure quality documentation to accurately reflect patient's severity of illness and risk of mortality

  • Collaborate with providers to clarify incomplete diagnosis in medical records
  • Using clinical judgment to identify clinical indicators and query physicians for presence of other diagnosis
  • Education of providers in the area of documentation improvement to best reflect patient's conditions
  • Assigned to Medical ICU
  • Developed analytic reports to identify discharged medical records with potential documentation improvement opportunities
Candidate Info
22
years in
workforce
3
years
at this job
BS
Bachelor of Science
BS
Public Health
MA
Master of Arts
25

Clinical Documentation Specialist

Perform concurrent reviews of medical records to ensure accurate documentation of medical necessity. These reviews include an assessment of severity of illness/risk of mortality, correct MS-DRG assignment, appropriate revenue capture, case mix index, and support for Core and Quality Measures.

  • Perform follow-up reviews to ensure diagnostic clarification queries have been answered.
  • Educate physicians and other healthcare professionals as needed regarding the relationships between documentation, coding, and quality.
  • Perform daily geometric mean length of stay (GMLOS) assignments on all inpatient cases, based on the working DRG for each case.
  • Formulate CDI queries [online and written] based on clinical indicators in compliance with organizational and federal [CMS/AHIMA] guidelines.
  • Educate CDI physician advisors on best practices for accurate coding and documentation.
  • Maintain CDI monitor database including response rate (99%), agreement rate (98%), tracking and trending of diagnosis clarification queries.
  • Collaborate with the coding department to ensure proper documentation of discharge diagnoses and comorbidities, in order to accurately reflect patients' medical records.
Candidate Info
11
years in
workforce
6
months
at this job
26

Clinical Documentation Specialist

  • Knowledgeable of ICD-10 CM and PCS coding principles and procedures
  • Interacted with physicians to ensure clinical documentation accurately reflected the level of service rendered to the patient and that coding could be completed.
  • Formulated detailed and concise queries regarding patient documentation and care for physician review and completion.
  • Monitored cases for severity of illness, risk of mortality data, quality control issues, physician and hospital outcomes.
  • Utilized software system, Epic and 3M, to track data and report outcomes
Candidate Info
14
years in
workforce
9
months
at this job
BS
Business Administration
BS
Nursing
MS
Family Nurse Practitioner
27

Clinical Documentation Specialist / Certified Medical Coder

  • Clinical Documentation Specialist and coder (ICD-9 and ICD-10) of outpatient clinics (day surgery and wound care clinics)
  • Reviews clinic charts and works closely with the doctors, nurses, and ancillary staff of clinics in order to improve documentation through clinic visits and queries.
  • Inpatient Clinical Documentation Specialist (occasional)
  • Attended weekly length of stay meetings, met with Chief Medical Officer to discuss selected cases, reviewed medical records and communicated in person and through queries in order to improve documentation
Candidate Info
7
years in
workforce
3
years
at this job
BA
Health Administration
MA
Public Health
MD
Doctor of Medicine
28

Clinical Documentation Specialist

Review Medicare and Medicare HMO charts to identify that the clinical documentation reflects the care given to patient during hospitalization.

  • Identify query opportunities on each case and implement effective query process.
  • Work with various physician groups on continual education of DRG's, co-morbities and major co-morbities for appropriate documentation of each case.
  • Active participation in daily huddle meetings with physicians, case managers, discharge planning and shift leaders to discuss DRG's and GLOS.
  • Assign DRG for each case reviewed.
  • Utilize 3M to code each chart reviewed.
  • Active participation with continual coding education to prepare for ICD10.
  • Effective utilization of Allscripts reports and data.
Candidate Info
15
years in
workforce
3
years
at this job
BS
Nursing
29

Clinical Documentation Specialist

  • Provided specialized support to the Clinical Trial Team in planning, execution, and control of clinical trial regulatory documentation
  • Processed regulatory documentation associated with Clinical Study Start-up and Close-out.
  • Monitored IRB approvals and annual renewals
  • Compiled CSR appendices sections (per ICH E3 Guidelines).
Candidate Info
3
years in
workforce
2
years
at this job
BS
Technology Management
30

Clinical Documentation Specialist

Review, examine, and use expert clinical knowledge base to ensure proper health record documentation by physicians.

  • Expert knowledge of health care reform language
  • Expert knowledge of JA Thomas and Associates CDMP software
  • Expert knowledge of CMS and coding guidelines and continuing changes.
  • Continuing education preparation and presentation for physicians and nurses.
  • Multiple research and pilot projects for Chief Medical Officer
  • In depth and on-going knowledge of ICD-9 coding system
Candidate Info
43
years in
workforce
6
years
at this job
AS
Associate of Science
BS
Health Administration, Management

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