Clinical Documentation Improvement Specialist Resume Examples

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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Clinical Documentation Improvement Specialist Resume Samples

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Candidate Info

9

years in workforce

1

year at this job

BA

Biological Sciences

MA

Biomedical Science

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

28

years in workforce

3

years at this job

AS

Nursing

BS

Chemistry

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

4

years in workforce

7

months at this job

BS

Psychology

MD

Medicine

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

5

years in workforce

1

year at this job

BS

Integrative Neuroscience

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

1

year in workforce

1

year at this job

AS

Health Information Management

BS

Nursing

MA

Informatics

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

15

years in workforce

8

months at this job

BS

Nursing

MS

Nursing

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

10

years in workforce

1

year at this job

BS

Nursing

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

25

years in workforce

9

years at this job

AS

Nursing

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

11

years in workforce

2

years at this job

C

Health It

BS

Health Information Management

Acdis Cdi Bootcamp March 2016

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

30

years in workforce

5

years at this job

HS

Practical Nursing

BS

Nursing

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

14

years in workforce

1

year at this job

AS

Nursing

Clinical Documentation Improvement Specialist/ Query Writer

Queries physicians regarding missing, unclear, or conflicting health record documentation by requesting and obtaining documentation within the health record. Promotes appropriate clinical documentation to accurately reflect the patient's severity of illness, working diagnosis, and clinical course of hospitalization.
Exhibits a sufficient knowledge of clinical documentation requirements, MS-DRG Assignment, and clinical conditions or procedures.
Follows guidelines for coding and documentation to ensure physicians and hospital compliance. Remains current with coding information to ensure accuracy of codes assigned based on documentation.
Responsible for improving the overall quality and completeness of clinical documentation. Supports the accuracy and completeness of clinical information used for measuring and reporting physician and medical outcomes
Improve documentation of all conditions and treatments in the discharged medical record to ensure an accurate reflection of the patient condition in the associated DRG, case mix index, severity of illness, risk of mortality, profiling and reimburesemnt.
Analyzed aggregated data to identify patterns and areas of focus for documentation and coding improvement initiatives/education.
Implement strategies for sustained work process changes that facilitate complete, accurate clinical documentation.
Plans, performs or supervises audits. Develops an audit corrective action plan for improvement and monitors compliance with the plan.
Assists with coding and CDI questions, provides guidance memos on coding and clinical documentation related issues/topics.
Develops and educates the coding and CDI staff, as well as physicians if necessary, in understanding the coding and clinical documentation requirements for diagnosis capture, in al with regulatory standards and coding guidelines.

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