A professional Clinical Documentation Specialist job role is to evaluate and assess the medical records of patients that are drawn from various departments such as – cardiac care, medical units, telemetry, and intensive care. The Typical daily workflow listed on the Clinical Documentation Specialist Resume includes – monitoring the quality of patient records, recommending strategies to improve record keeping procedures, assessing patient record to check its accuracy, educating juniors or other department staff about the importance of maintaining accurate records, ensuring that the patient chart contains the right treatment plans, proper coding and billing; and finally ensuring that the standard regulations and policies are followed.
Possessing these career skills will be useful – exceptional analytical and critical thinking skills, knowledge of database maintenance software and EHS; a deep understanding of clinical conditions and medical coding processes, and knowledge of accepted quality assurance procedures. While an entry-level position will need only an education ranging from high school diploma to a GED, Specialist position will require an advanced study such as a Master’s degree in health information system or the related fields.
Objective : Assured compliance with University regulations, Code of Federal Regulations (CFR), International Conference of Harmonization (ICH), and GCP guidelines Maintained current regulatory documentation.
Skills : Microsoft office, MS-Excel.
Description :
Facilitated of concurrent modifications to clinical documentation to support the care provided.
Developed and retained the CDI process that adheres to the compliance of coding/query/DRG/CC/MCC assignment.
Completed documentation to measure and report physician and hospital outcomes and treatment settings.
Educated of internal customers on documentation opportunities, coding and reimbursement issues, and performance improvement methodologies.
Created of job aids and queries to support training. Knowledge of ICD-10 coding and documentation requirements, policies, and procedures.
Documented reviews to ensure clarification has been recorded in the patient's chart.
Reviewed clinical issues with coding staff, nurses, and others to ensure appropriate inpatient technical diagnosis.
Experience
0-2 Years
Level
Entry Level
Education
MBBS
Clinical Documentation Specialist II Resume
Headline : Dedicated RN experience with medical-surgical, pediatrics, as well as pre-op surgery. Joined newly created clinical documentation team leading the initiative for better coding and reimbursement for the hospital.
Skills : Clinical Social Work, Administrative Social Work, Office Equipment.
Description :
Responsible for reviewing medical records to ensure the accurate representation of the severity of illness and improving the quality.
Provided accurate and timely record reviews of patient charts to recognize opportunities for clinical documentation improvement.
Formulated clinically credible queries to notify physicians and healthcare providers of chart deficiencies requiring clarification.
Maintained effective and appropriate communication with physicians and healthcare providers.
Conducted follow up reviews of charts to ensure points of clarification have been addressed.
Maintained communication with coding staff to help resolve any inconsistencies in physician charting.
Served as a resource to physicians and other healthcare providers in matters relating to DRG information.
Experience
5-7 Years
Level
Executive
Education
Nurse Practitioner
Clinical Documentation Specialist/Analyst Resume
Headline : Process of transitioning from current residence in Connecticut to new home in Upstate. Seeking to obtain a Nursing position in that geographic region, which builds on and /or broadens existing knowledge.
Skills : OR Circulator, Some Scrubbing, Med-Surg Nursing.
Description :
Reviewed patient medical records for accuracy and specificity of clinical documentation.
Accessed and reviewed patient information via electronic data management systems for additional pertinent information.
Communicated with physicians via a query process to improve the quality of documentation within the patient record.
Maintained a computerized data form to track workflow and outcomes.
Worked together with clinical coding staff to ensure the most accurate reporting/billing of patient accounts.
Gathered data for quality improvement in the Clinical Documentation Specialist, CDI process.
Identified variances from practice and policy and participate in the education of physician staff.
Experience
5-7 Years
Level
Executive
Education
Nursing
Clinical Documentation Specialist I Resume
Objective : Foreign medical doctor with experience in treating patients for a variety of conditions in out-patient and in-patient settings. Areas of interest include General Surgery and Traumatology, Pediatrics.
Skills : Microsoft Office, Technical Skills.
Description :
Submitted recommendations to the medical director along with medical guidelines for a final decision.
Able to meet all Health Plans' guidelines requirements and satisfying the utmost patient's health care quality in a cost-effective measure.
Performed TAR reviews and completion of TAR requests according to CMS format and deadlines.
Performed clinical medical file review of hospital documentation for necessary clinical treatment and patient severity of the illness.
Performed on-line documentation of clinical justification for hospital stays and pre-screening of files to determine if Appeal is warranted.
Documented clinical justification for Appeal requests. Conduct a clinical review of cases that do not meet the criteria.
Reviewed are done on all commercial insurance patients and all Medicare, Medical.
Summary : Seeking a Nurse Practitioner position in either an inpatient or outpatient setting that will utilize skill and abilities in the evaluation, and treatment plan development for patient centered care in a cost-effective manner.
Skills : Clinical Social Work, Administrative Social Work.
Description :
Facilitated & evaluated the effectiveness & impact of programs. Cleanse, modify, & edit data fields to accuracy.
Administered Coordination ability to read, analyze, & interpret procedural documents & clinical records.
Managed & interpreted data, establish facts, and organize details.
Collaborated with the Executive & Management Teams to identify inconsistencies in the documentation and arrive at solutions.
Assisted the Director of Quality Assurance in troubleshooting and finding solutions.
Reviewed to assign correct drg for in a hospital inpatient unit as per CMS, AP/APR standard.
Reviewed hospital inpatient medical records both new admissions and stay patients in preparation for coding of diagnosis and procedures.
Summary : Understandable requirements for onsite training to ensure success. Professional experiences include management experience. Clinical chart review, auditing, CDI, and coding experience.
Collaborated with physicians, case managers, and Health Information Management Coders to identify areas for improved physician documentation.
Conducted initial -concurrent and retrospective reviews and document findings.
Diagnosed and procedure codes to accurately reflect the patient's severity of illness.
Worked collaboratively with the healthcare team.
Facilitated documentation to support the patient's severity of illness and risk of mortality.
Tested to provide a standardized documentation tool. Follow through with physicians to obtain a timely response to physician queries.
Developed educational presentations and in-services to physicians and ancillary staff.
Experience
7-10 Years
Level
Management
Education
Nursing
Clinical Documentation Specialist III Resume
Summary : As a documentation review nurse with a clinical background in the Emergency Room, seeking a medical review or auditor role which can make the most of skill set.
Skills : Microsoft Office, Hard Working.
Description :
Identified the need to clarify documentation & queries physicians using appropriate methods of communication.
Provided information & education to physicians & other providers specific to clinical documentation.
Systematically tracked summarize, & reports indicators of program effectiveness.
Identified trends or process problems & assists in developing corrective action plans.
Performed targeted retrospective record reviews when indicated for performance improvement purposes.
Actively participated in projects designed to reduce costs, capture lost revenue, or enhance efficiency.
Developed& maintained a working knowledge of current reimbursement methods & regulations pertinent to clinical documentation & coding.
Summary : Working in a clinical environment, healthcare IT, EHR implementation, health information management and medical records department Experience in Epic Optime-Anesthesia application build.
Skills : 3m 360, Cerner, MS-Excel.
Description :
Responsible for requirement gathering from the hospital end-users, clinical documentation forms build, design analysis.
Created data elements to capture key health information automatically.
Workflow analysis to provide the most efficient documentation functionality within the EHR application.
Tested with the end-user to validate the auto coding functionality.
Identified issues and sharing strategies for improvement within the team.
Participated in Epic project periodic meetings/discussions with key stakeholders.
Summary : A versatile, dedicated medical professional who can bring organized and efficient management to medical and clinical documentation. Proficient at identifying and retrieving or reviewing.
Skills : Microsoft Excel, 3M 360, Morrisey Concurrent Care Manager.
Description :
Encompassed for concurrent review and coding of the medical record along with Cerner.
Identified the need to clarify documentation and queries physicians using appropriate methods of communication.
Provided information and education to physicians specific to clinical documentation.
Systematically tracked summarize and report indicators of program effectiveness.
Developed and maintained a working knowledge of current reimbursement methods and regulations pertinent to clinical documentation and coding.
Developed and maintained a collaborative relationship with medical, case management, and HIM personnel.
Tracked 30-day readmissions to establish patterns and cause.
Experience
10+ Years
Level
Senior
Education
Nursing
Lead Clinical Documentation Specialist Resume
Summary : Seeking an opportunity to utilize unique background and experience in medicine, clinical documentation, six sigma and hospital administration to help advance the healthcare goals.
Skills : Customer Service Representative, Microsoft Word, Microsoft Excel.
Description :
Collected information about patients' diagnoses and enters them into computer databases.
Assessed all patient medical documents to ensure accuracy.
Educated medical coders and billers on standard procedures that must be followed when composing medical documents.
Recommended strategies for improving record-keeping processes.
Ensured all clinical documents are in compliance with federal laws in terms of composition and secure storage.
Analyzed medical information to assist healthcare staff in providing superior services for patients.
Applied knowledge of medical terminology and medical procedures to properly evaluate clinical documents.
Experience
7-10 Years
Level
Management
Education
BS
Clinical Documentation Specialist Resume
Objective : Patient service oriented Physician with bachelor degree in Medicine, Strong background in clinical pharmacology and patient medication therapy management. Disciplined and confident physician licensed.
Skills : Medical Records, Data Mining, Report Preparation.
Description :
Responsible for document control of incoming documents.
Utilized Excel spreadsheets to track documents regarding patient information.
Corresponded with various practices to facilitate the signing and tracking of Physician Orders and Authorization Forms from multiple boroughs.
Located medical files for staff nurses upon request.
Prepared medical files for scanning under weekly deadlines.
Filed daily incoming updates to patient EMR. Converted paper files in electronic files.
Located discharged and deceased patient files to update and file accordingly.
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