Clinical Documentation Improvement Resume Samples

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CL
C Legros
Cara
Legros
905 Allison Shoals
Los Angeles
CA
+1 (555) 367 3089
905 Allison Shoals
Los Angeles
CA
Phone
p +1 (555) 367 3089
Experience Experience
New York, NY
Clinical Documentation Improvement
New York, NY
Walker-Jacobson
New York, NY
Clinical Documentation Improvement
  • Review inpatient medical records for identified payor populations (i.e., Medicare, Medicaid, Managed Care etc.) as directed on admission and throughout hospitalization, analyzing clinical status of patient, current treatment plan and past medical history and identifies potential gaps in physician documentation
  • Ensure that clinical documentation reflects the level of service rendered to patients in complete, accurate and compliant with the regulations of the Center for Medicare and Medicaid Services
  • Perform initial charts reviews and assign working DRG within 24 hours of admission, on the working days
  • Assist in the development of compliant diagnosis/DRG specific queries to aid physicians with proper and precise documentation
  • Maintain up to date working DRG and has clear strategies to effectuate improved quality of clinical documentation for all the select cases
  • Regularly participate in scheduled case management meetings and actively exchange information pertaining to clinical documentation, plan of care affecting coding and reimbursement
  • Take responsibility in addressing medical necessity issues through concurrent review process, initiating compliance with CORE measures before discharge and assisting in follow-up on queries and clarifications to physicians concurrently and retrospectively
Dallas, TX
Director of the Clinical Documentation Improvement
Dallas, TX
Murray-Fahey
Dallas, TX
Director of the Clinical Documentation Improvement
  • The individual will promote accurate concurrent documentation from all disciplines (physicians, case managers, nurses, dietitians, wound care specialists etc.) to capture best practice documentation for specific diagnoses. He/She will also conduct regular retrospective reviews for coding accuracy, missed opportunities, consistency of documentation and education of CDS and coding staffs
  • The individual should meet or exceed expected time lines on performance level related to personnel, budgeting and reporting responsibilities
  • This role serves as a translator between Finance and the Clinical Staff, and plays a vital role in improving accurate quality reporting for both provider and the facility
  • The individual will monitor performance of staff under him/her using departmental KPIs
  • The position provides strategic planning and concentrated daily oversight of the Clinical Documentation Improvement Program
  • The individual will provide ongoing education to all members of the medical staff
  • The individual will be responsible for development and execution of CDI program for assigned Prospect Medical Holding Hospitals
present
Chicago, IL
Director Clinical Documentation Improvement Altamonte Springs
Chicago, IL
Hilll LLC
present
Chicago, IL
Director Clinical Documentation Improvement Altamonte Springs
present
  • Responsible for recruiting and providing support, guidance and mentorship to Clinical
  • Oversees expense including resource utilization for supplies and staff
  • Establishes and maintains communication with Financial Planning and Revenue Cycle Business Analytics team
  • Rehires within 12 months are not eligible
  • Contribute to the design and development of a clinical documentation improvement program in coordination with hospital and division leadership
  • Collaborate with peers regarding department budget and operational plan development to maintain fiduciary responsibility and achieve greater financial performance
  • Up-to-date knowledge of ICD-10 mandate and the impact of code set transition (e.g., potential impact on data quality for prospective payments, utilization, and reimbursement)
Education Education
Bachelor’s Degree in Nursing
Bachelor’s Degree in Nursing
University of California, Berkeley
Bachelor’s Degree in Nursing
Skills Skills
  • Effective oral and written communication skills, with the ability to articulate complex information in understandable terms to all levels of staff
  • Customer-focused attitude and ability to work proactively and efficiently with appropriate urgency
  • Strong organization skills
  • Effective computer skills, particularly Microsoft Office Outlook, Word, Excel
  • Ability to work in a matrix-management environment to achieve organizational goals
  • Ability to establish and manage complex and effective relationships
  • Excellent analytical and problem-solving skills
  • Up-to-date knowledge of ICD-10 mandate and the impact of code set transition (e.g., potential impact on data quality for prospective payments, utilization, and reimbursement)
  • At least seven to ten years’ acute hospital clinical experience
  • Ten plus years of experience in a clinical documentation improvement program
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7 Clinical Documentation Improvement resume templates

1

Director of Clinical Documentation Improvement Resume Examples & Samples

  • 5+ years of experience doing Clinical Documentation Improvement (CDI)
  • Experience managing people in a CDI setting
  • Excel proficient
  • ICD-10 training
2

Clinical Documentation Improvement Manager Resume Examples & Samples

  • Minimum of three years as a lead clinical documentation specialist
  • Advanced clinical expertise and extensive knowledge of complex disease processes with broad based clinical experience in an inpatient setting
  • Expertise in MSDRGs, ICD coding and CDI practices required
  • Expertise in CDI practices and knowledge distribution to multidisciplinary teams
  • Proficiency with Microsoft Applications, including word processing, spreadsheets and presentation software
  • Extensive knowledge and experience in reporting software and electronic medical record systems
  • Maintains working knowledge of Medicare/Medicaid rules and regulations regarding CDI, POA (present on admission), basic coding, as well as current trends and developments in the area of Clinical Documentation Improvement (CDI)
  • Ability to work with senior management, physicians, and medical center staff with various levels of education and experience
  • Ability to develop and maintain strong, collaborative and supportive working relationships with CDI peers, physicians and other clinical professionals
  • Must have demonstrated interpersonal, verbal and written communication skills in dealing with multidisciplinary teams and variety of ongoing activities
  • Knowledge of project management processes and systems
  • Knowledge of statistical analysis and reporting practices pertaining to quality improvement and program evaluation
  • Demonstrated organizational, project management skills
  • Ability to be creative and innovative in a high volume work environment
  • Ability to lead teams and produce project results within schedule and budget
  • Ability to plan, organize, motivate, mentor, direct and evaluate the work of others
  • Ability to provide leadership and influence others
  • Skilled and experienced in data analysis and qualitative reporting of results
  • Skill in developing and delivering training and education to clinical, CDI and coding professionals regarding CDI practices, coding and documentation requirements
  • Demonstrated organizational and critical thinking skills, ability to assess, evaluate and teach
  • Skilled in adaptability and self-motivation in staying abreast of CDI practices, coding changes and clinical practices
  • Demonstrated judgment and independent decision making
  • Valid Registered Nurse license or foreign medical graduate. CCS or ACDIS certification
3

Clinical Documentation Improvement Principal Consultant Resume Examples & Samples

  • Obtain appropriate clinical documentation through extensive interaction with physicians, nursing staff, other patient care givers, and in collaboration with Health Information Management coding staff to ensure that appropriate reimbursement is received for the level of services rendered to patients and the clinical information utilized in profiling and reporting outcomes is complete and accurate
  • Use of extensive knowledge of documentation requirements and guidelines in accordance with Coding Clinic to improve the overall quality and completeness of clinical documentation by performing admission/continued stay reviews using clinical documentation guidelines
  • Educate internal staff on clinical documentation needs, changes to clinical documentation guidelines, coding and reimbursement issues and conduct follow up reviews of clinical documentation to ensure points clarified with the physician have been recorded in the patient’s record
  • Review clinical issues with the coding staff to assign a working DRG
  • Participate in patient care conference/case conferences to identify needs for clinical documentation, case management, and utilization review
  • Expected to be a super-user for the Precyse CDI technology and CDI dashboards
  • Expected to participate in routine team meetings
  • Expected to keep abreast of new legislation and regulations that affect CDI, Case Management (CM) and Utilization Review (UR)
  • Provide input for reporting of metrics and measures of CDI, CM, and/or UR program activity to hospital executive and medical leadership
  • Maintain personal and professional education and growth
  • Make travel plans timely and according to policy
  • Coordinate and oversee the client project management duties and assure scope of work is delivered timely and within budget
  • Coordinate and lead the team in the performance / management of CDI, CM, and/or UR program assessment duties. These assessment duties include but not limited to: medical record reviews, CDI, CM, UR staff competencies, process flow, review of P&P, interviews, etc. Completes and delivers an assessment report to client
  • Coordinate and lead the consulting team in the performance / management of CDI, CM, and/or UR program implementation duties
  • These implementation duties include but not limited to: Education of CDI staff, Physician, Ancillary staffs, process flow redesign and implementation, staff mentoring, review of performance metrics, participation in steering committee and other meetings, etc. Complete and deliver an implementation report to client
  • Coordinate and lead the team in the performance / management of CDI, CM, and/or UR program follow-up duties
  • These duties include but not limited to: medical record reviews, staff competency assessments, process flow, review of P&P, interviews, etc. Complete and deliver a follow-up report to client
  • Responsible for providing education and training on clinical documentation improvement principals and methodology (MS-DRG and APR-DRG as appropriate) to the Strategic Sourcing clients, Consulting Practice, and new clients
  • Educate team and clients on Precyse CDI technology and associated work flows during implementations that combines CDI services and technology
  • Work in collaboration with Director of Clinical Services Consulting Practice to develop / refine education materials, participate in internal training and client management
  • Supports Precyse's Compliance Program by demonstrating adherence to all relevant compliance policies and procedures as evidenced by training participation and daily practice; notifying management when there is a compliance concern or incident; demonstrating knowledge of HIPAA Privacy and Security Regulations as evidenced by appropriate handling of patient information; promoting confidentiality and using discretion when handling patient information
  • Must have high speed internet access and experience with remote access, set-up, and troubleshooting technical issues when working remotely
  • Weekend travel may be required on occasion
  • RN or MD Required. Bachelor's Degree required
  • Consulting experience required
  • In addition to education, recent 3 to 5 years of well-rounded medical or surgical acute care nursing and/or critical care nursing experience required
  • Technical knowledge of ICD-9 and ICD-10, DRG and APR assignment and prospective payment methodologies required
  • Strong knowledge of clinical documentation and medical necessity guidelines required
  • Must be able to speak clearly and concisely while presenting
  • Must be willing to be published
  • Ability to write reports independent of management review
  • Requires strong interpersonal skills to work with key stakeholders, physicians and/or clients and staff to implement positive/effective change
  • Must take initiative to address critical issues
  • Ability to think critically and analytically, anticipate challenges and trends required
  • Must be able to demonstrate initiative and the ability to work in a fast paced environment with proficiency in multi-tasking and prioritization
  • Strong working knowledge of computer technology. Computer knowledge of MS Office, including Word, Excel, and PowerPoint is required
  • CCDS, CDIP, CCS, ACM, CCMC preferred
  • 3+ years of CDI and/or CM/UR experience required. Experience in both areas preferred
4

Clinical Documentation Improvement Senior Consultant Resume Examples & Samples

  • Use your extensive knowledge of documentation requirements and guidelines in accordance with Coding Clinic to improve the overall quality and completeness of clinical documentation by performing admission/continued stay reviews using clinical documentation guidelines
  • Verify clinical documentation against final coding and modify CDI technology entry in order to report valid CDI outcomes
  • Reviews clinical issues with the coding staff to assign a working DRG
  • Participate in patient care conference/case conferences to identify needs for clinical documentation
  • Maintain current skill set with regard to government regulations, compliance and reimbursement guidelines
  • Expected to keep abreast of new legislation and regulations that affect CDI
  • Provide input for reporting of metrics and measures of CDI program activity to hospital executive and medical leadership
  • Maintains personal and professional education and growth
  • Responsible for maintaining continuing education credits as required by credentialing organization
  • RN Required. Bachelor's Degree or MD (medical degree) a plus
  • Clinical documentation improvement experience highly preferred
  • CCDS, CDIP, or CCS preferred
  • In addition to education, 3 to 5 years of well-rounded medical or surgical acute care nursing and/or critical care nursing experience required
  • Inpatient coding experience a plus
  • Technical knowledge of ICD-9 and 10, DRG and APR assignment and prospective payment methodologies preferred
  • Strong knowledge of clinical documentation guidelines required
  • Must be detail oriented, have the ability to work independently, exercise good judgment and be resourceful
  • Must display proficient communication skills, both written and verbal
  • Ability to write reports independent of management review is a plus
  • Experience and/or knowledge of regulatory compliance issues facing the healthcare industry is also a plus
  • Ability to manage execution by balancing time, resources, and quality constraints to achieve goals required. Focused on team and collaboration
  • Must take initiative to address critical issues. Ability to think critically and analytically, anticipate challenges and trends required
  • Working knowledge of automated system designs is preferred
  • Experience in computerized hospital/health information management systems and software applications is required
  • CDI Outpatient, Case Management and UR experience a plus
5

Senior Director Clinical Documentation Improvement Resume Examples & Samples

  • Direct experience in working as a CDI Leader or in development of CDI program in the acute care setting and understanding of CDI program infrastructure, workflow and reporting/metrics
  • Experience leading a large scale consulting project or driving implementation of a client CDIP
  • Proven success in delivering value to customers through the CDI programming
  • Strong communication skills including the abilities to present effectively, actively listen and influence/negotiate
  • Experience in conducting gap analysis, identification of risk and opportunity and development of findings and recommendations, including development of a Road Map
  • CDIP gap analysis experience preferred but qualified candidates may have comparable experience with other similar initiatives
  • Strong understanding of both clinical, HIM, Quality and Case Management workflow
  • Clinical Documentation Improvement Specialist/Professional (CCDS/CDIP) credentials through AHIMA or ACDIS
  • Direct experience in working as a CDI Specialist or in development of CDI program in the acute care setting and understanding of CDI program infrastructure, workflow and reporting/metrics
  • Experience in conducting gap analysis, identification of risk and opportunity and development of findings and recommendations, including development of a Road Map; CDIP gap analysis experience preferred but qualified candidates may have comparable experience with other similar initiatives
  • Individual must be proficient in ICD10 Diagnosis/Procedures Codes, MS-DRG reimbursement and clinical documentation requirements (coder credentials not required)
  • Has facilitated physician education or has experience in working directly and communicating with physicians
  • Operational Leadership experience
  • MS degree
  • Preferred license/credential: RN, NP, PA, MD, RHIA, RHIT
6

Clinical Documentation Improvement Manager Resume Examples & Samples

  • Knowledge of MS-DRG classification and reimbursement structures
  • Ability to apply coding conventions, official guidelines, and Coding Clinic advice to health record documentation
  • Leadership and organizational skills along with critical, deductive reasoning and problem solving skills
  • Report writing with management review
  • Overall knowledge of the flow of the revenue cycle
  • Detail oriented and analytical skills
  • Manage change while minimizing interruption at an operational and service level
  • Preferred: Graduate from a Nursing program, BSN or graduate of Health Information Management RHIT, RHIA
7

Manager, Clinical Documentation Improvement Resume Examples & Samples

  • Coordinates and provides ongoing education to care providers regarding documentation requirements for optimal data integrity, data reliability, and clinical coding. Works with leadership to improve physician engagement
  • Performs frequent reviews of work performed by Clinical Documentation Specialists to assess quality of work performed. Provides additional education and guidance to staff when required
  • Guides, supports and sponsors the Hospital's Clinical Documentation Improvement efforts. In partnership with Clinical Coders, ensures patient classification and DRG assignment are supported by physician documentation and in compliance with rules, regulations and guidelines
  • Frequently monitors productivity of Clinical Documentation Specialists and addresses concerns when minimum levels are not met
  • Communicates and informs Director of status of program and identifies any obstacles in meeting goals and objectives. Develops strategies and provides suggestions to ensure program success
  • Works collaboratively with physicians, nurses, and ancillary providers to accurately represent each patient's signs, symptoms, diagnoses, and treatment plan
  • Acts as a liaison between the technical and clinical coding functions
  • Educates health team colleagues about coding and data management including role responsibilities, tools, methodologies, and anticipated outcomes
  • Partners with HIM and Revenue Cycle professionals in third party payer DRG audits and appeals
8

Clinical Documentation Improvement Product Consultant Resume Examples & Samples

  • Establish client relationships with key individuals such as but not limited to Director of Health Information Management department, Vice President of Revenue Cycle, Director of Clinical Documentation Improvement department, CIO and / or Practice / Office Managers during the implementation and post implementation process
  • Acts as a primary, detailed, hands-on expert for the product during the implementation and post implementation process
  • Work flow analysis, process redesign, user acceptance testing, training, go-live support and analytic review
  • Reviews sales assessment document and any other client information to determine scope of the project and potentially any implementation concerns
  • Participates in introduction call, scoping visit and discovery visit to review current workflow, analyze operational processes, and determine future workflow and operational processes
  • Addresses concerns to Project Manager, Director of Product Management and Vice President of Implementations, Technical Engineering and / or any other team appropriate within
  • Optum to optimize how the product and / or services will best integrate into the client’s processes and systems
  • Demonstrates clearly and effectively Optum’s Enterprise Computer Assisted Coding (CAC) application (hospital and professional), Coding Reimbursement Module and / or Clinical
  • Documentation Improvement Module and addresses client concerns and questions
  • Participates in weekly project meetings with members of the implementation team (internal and external) to review the project task plan and evaluate progress; provides input throughout the implementation and post implementation process
  • Documents and verbally communicates task status, progress to facilitate a smooth implementation, and / or any risk associated with the project
  • Primary organizer and trainer for user acceptance training and testing (UAT)
  • Conducts End User Training
  • Bachelors of Science Degree in Health Information Management, Healthcare Informatics, Clinical Documentation Improvement, Nursing, OR active RN license
  • 5 years of experience functioning as a software product and / or domain expert in large health care systems, healthcare practice management or the managed care space
  • 5 years of work experience in Clinical Documentation Improvement
  • Experience in managing large-scale projects where deadlines are met on or ahead of schedule
  • Experience in customer service skills (direct on-site client representation)
  • Ability to travel, including overnight, as needed up to 80% of time
  • Certified as an RHIA, RHIA, RN, CCS, or CPC
  • Proven leadership ability across all levels of an organization, including executive level (CxO)
  • Time management skills; ability to multitask and manage competing priorities
  • Strong written and verbal communication skills that can effectively communicate with a diverse workforce
  • Executive presence and interaction skills
  • Strong interpersonal and negotiation skills, with a high degree of self-motivation and ability to work independently through effective influencing
  • Strong process orientation, problem solving and troubleshooting skills and a firm commitment to quality
9

Division Director of Clinical Documentation Improvement Resume Examples & Samples

  • Maintains up-to-date working knowledge of Medicare/Medicaid rules and regulations regarding CDI, basic coding, as well as current trends and developments in the area of Clinical Documentation Improvement
  • Develops and implements CDI strategies, capitalizing on facility best practices. Provides facility specific CDI analysis and makes recommendations for process improvement. Ensures that improvement opportunities are appropriately channeled to effect change
  • Intervenes with facility CDI programs to address and resolve issues related to facility CDI process. Provides guidance and strategic direction on CDI issues
  • Facilitates strong working relationships between Shared Service Center (SSC), Coding, and hospital departments to promote effective clinical documentation improvement through coordination of efforts
  • Collaborates with HIM and hospital on delinquent queries and month end close processes to ensure accuracy of interim coding on unbilled accounts
  • Supports hospital initiatives in meeting core measures, patient safety and service excellence goals
  • Identifies educational opportunities and coordinates division and facility based training programs. Facilitates orientation of new CDI staff
  • Monitors and analyzes trends in the CDI process. Develops and implements action plans to maximize the CDI program in the division
  • Facilitates the development and review of division/facility CDI plans to ensure compliance with internal audits, state and federal regulatory requirements. Performs chart reviews to ensure appropriate documentation
  • Fosters effective communication and collaboration with physicians and/or provides training and education related to CDI process. Works with Physician Advisors to address outlier physicians. Monitors and addresses low physician response and agree rates to queries
  • 3-5 years hospital relevant work experience in Clinical Documentation. Minimum 2 years Director/Manager or Supervisory experience required
10

Clinical Documentation Improvement Director Resume Examples & Samples

  • Assures appropriate reimbursement and administrative data-driven quality metrics through documentation improvement activities
  • Develops and delivers basic, intermediate and advanced level education for CHS physicians, coders, CDIS and leadership relating to
  • Keeps abreast of regulatory changes related to coding and documentation and communicates these changes to appropriate corporate and hospital staff
  • Maintains a thorough knowledge of the Medicare Inpatient Prospective Payment System
  • Possesses an excellent understanding of coding practices, official coding guidelines and federal regulations
  • Maintains a broad knowledge of ethical and compliant query practices
  • Maintains a broad knowledge of the clinical aspects of diagnoses and procedures to ensure appropriate documentation and compliance with respect to regulatory requirements for coding and billing
  • Possesses a broad knowledge of pharmacological usages and related adverse reactions
  • Maintains auditing skills for coding quality and documentation
  • Possesses the ability to develop and present effective education via a variety of media platforms
  • Possesses the ability to produce and analyze reports in a variety of platforms
  • Completes other duties, as assigned
  • Degree concentration in Health Informatics and Information Management, Health Care Administration, or clinical background such as Registered Nurse or comparable clinical experience
  • Three to five years of experience in an acute care hospital setting required
  • Three years of experience in providing physician and coder education required
  • Minimum of three years of clinical documentation improvement experience required
  • Must exhibit extensive knowledge of healthcare regulations, including reimbursement and documentation requirements
  • Must exhibit extensive knowledge of documentation requirements for severity of illness, risk of mortality, APR-DRGs and quality outcomes data
  • Previous experience working in a clinical documentation improvement department or as a consultant required
  • Minimum of one-year auditing experience preferred
11

Director of Clinical Documentation Improvement Resume Examples & Samples

  • 5 years experience in a CDI program with at least 3 years of experience as a manager or director in an acute care setting is required
  • Experience in conducting gap analysis, identification of risk/opportunities and development of findings and recommendations is required
  • Subject matter expertise in the area of clinical documentation to ensure the completeness of the patient records using multidisciplinary and interdisciplinary teams
  • High degree of hospital coding knowledge, including but not limited to APR-DRG, MS-DRG, HCCs, Medicare, Medicaid & Managed Care, in order to design and develop strategies to yield improvements to documentation that will improve overall patient quality, capture severity, assess acuity and determine risk of mortality
  • Thorough knowledge of clinical documentation requirements, clinical procedures, disease processes, treatments, and the patient populations served
  • Subject matter expertise regarding quality and reimbursement implications of clinical documentation and coding
  • Up-to-date knowledge of ICD-10 mandate and the impact of code set transition, including potential impact on data quality for prospective payments, utilization, and reimbursement
  • Demonstrated familiarity and adept use with software and technical applications including but not limited to: Microsoft Office products (Outlook, Excel, Word, PowerPoint), Epic (Electronic Health Records), Quantum (end coders), Midas (databases)
  • Quantitative analysis skills to include spreadsheet applications and statistics
12

Director of the Clinical Documentation Improvement Resume Examples & Samples

  • The individual will be responsible for development and execution of CDI program for assigned Prospect Medical Holding Hospitals
  • The individual will be responsible in ensuring that all staffs under him/her are adequately trained and equipped to carry out their daily clinical documentation work
  • The individual will monitor performance of staff under him/her using departmental KPIs
  • The position will play a key role in ensuring the success of major revenue cycle initiatives
  • The position provides strategic planning and concentrated daily oversight of the Clinical Documentation Improvement Program
  • The individual will define, implement and monitor strategies for improving clinical documentation resulting in quality of care, optimal case mix index and overall consistency of clinical documentation and coded data
  • The individual will facilitate modifications to clinical documentation through extensive interaction with physicians and midlevel providers, nursing staff, other patient caregivers and medical records coding staff to ensure that appropriate reimbursement is received for the level of service rendered to all patients with a DRG based payor (Medicare, Medicaid, other payers)
  • The individual, in conjunction, with other department heads (HIM, Case Management, Quality) will lead the effort to ensure that accurate DRG-based reimbursement for the hospital is achieved and claim denials are reduced, by ensuring documentation integrity
  • The individual will promote accurate concurrent documentation from all disciplines (physicians, case managers, nurses, dietitians, wound care specialists etc.) to capture best practice documentation for specific diagnoses. He/She will also conduct regular retrospective reviews for coding accuracy, missed opportunities, consistency of documentation and education of CDS and coding staffs
  • The individual will ensure the accuracy and completeness of clinical information used for measuring and reporting physician and hospital outcomes
  • The individual will develop strategies that will address risk adjustment and other quality measures that address hospital and physician performance
  • The individual will ensure that his/her team is abreast with regulatory and compliance changes that impact the department’s operation
  • The individual will review data/metrics with providers at Medical staff meetings as well as on individual physician basis
  • The individual will provide ongoing education to all members of the medical staff
  • The individual will facilitate optimal collaborative relationships with the medical staff including education opportunities, utilization management, health information management and other clinical staff
  • The individual will evaluate regulatory changes and educate staff appropriately
  • The individual should have regular, reliable, predictable attendance in performance of essential job functions
  • The individual should meet or exceed expected time lines on performance level related to personnel, budgeting and reporting responsibilities
  • The individual should have a thorough understanding of denials management and clinical appeal and will play an active role in denials management through formulation of strategies to minimize denials and drafting of credible appeals
  • The individual will work with hospital leadership, physicians, and other providers to improve the overall quality and completeness of clinical documentation in the medical record to ensure that an accurate reflection of the severity of illness and the quality of care is captured
  • The individual will work to educate providers on the value of more granular documentation to their quality scores, risk of mortality data, length of stay, and continuity of care for the patient
  • This role serves as a translator between Finance and the Clinical Staff, and plays a vital role in improving accurate quality reporting for both provider and the facility
  • The role will interface with compliance, management, and key physician leaders at the hospital as it prepares strategically for a competitive future
  • The individual will perform other departmental duties listed in the position description and as assigned
13

Clinical Documentation Improvement & Utilization Management Specialist Resume Examples & Samples

  • Minimum of 5 years of clinical healthcare experience in an acute care hospital
  • Knowledge base of ICD-10-CM coding and understanding of Diagnostic Related Groups (DRGs) required
  • Minimum 5 years recent health information management, case management / utilization / quality review and/or other related clinical experience in an acute care facility required; 3 years acute care inpatient coding experience preferred
  • Minimum of 2 years of acute care case management experience preferred
  • Minimum of 2 years of acute care clinical documentation specialist experience preferred
  • Knowledge of PC based computer software (i.e Word, Excel, Access or similar system) preferred
  • Graduate of an accredited school of nursing or Health Information Management program
  • BSN, RHIA or RHIT preferred
  • Working knowledge of Microsoft computer applications; excel, word, PowerPoint, etc
  • Excellent written, verbal and presentation skills required; excellent business judgment, decision making, and business savvy are also essential
  • Experience working collaboratively with IT, HIMS, and Clinical Operations are important
  • Strong understanding and appreciation for the automation of the revenue cycle functions and the engagement of the customer in that automated process
  • Knowledge of applied statistics, process analysis, and outcomes analysis
14

Clinical Documentation Improvement Team Leader Resume Examples & Samples

  • Utilizes critical thinking skills based upon extensive knowledge of disease processes and clinical outcomes to identify the need for further clarification of physician documentation within the medical record
  • Ensures that all written requests to physicians for additional documentation support compliance and departmental policies
  • Demonstrates the ability to prioritize daily work activities is self-directed and is able to complete daily work assignments with limited supervision
  • Performs quality screening for assigned patient for accurate assignment of a PSI and HAC to inpatient encounters
  • Assists with and analyzes outcome data relevant to the target case type to promote complete and accurate documentation
  • Analyzes and evaluates the effect of CDI on quality outcomes, fiscal parameters, and system operations and implements strategies to resolve system, performance and patient variances
  • Maintain and update the CDI Dashboard to track CDI measures of success and bench mark department effectiveness
  • Serves as a liaison between the CDI team and the medical staff
  • Collaborates with physicians and appropriate healthcare providers regarding documentation requirements and trends, as needed
  • Provides classroom and one-on-one training for CDI staff including initial CDI process and concept training and on-going education related to new topics in CDI, coding and reimbursement in conjunction with CDI Manager
  • Develops and provides formal and informal physician and staff education related to documentation improvement
  • Attends educational programs to enhance knowledge of clinical area served
  • Leads and/or participates on committees within the department, and TGH relevant to clinical documentation improvement
  • Assists in audits of CDI team as needed, makes appropriate recommendations for workflow improvement and accuracy as needed
  • Collaborates with Coding leadership and serves as a as a liaison between departments
  • Performs reconciliation of charts and differences in DRG assignments
  • Adhering to the Association of Clinical Documentation Improvement Code of Ethics and American Health Information Management Association’s code of ethics related to query process
  • Works with providers related to query responses, education and training
  • RN, Bachelors Degree
  • Certified Documentation Improvement Practitioner (CDIP), Certified Clinical Documentation Specialist (CCDS) or obtain and maintain certification within one year of employment
  • Greater than 5 years clinical experience and greater than 3 years experience as a Clinical Documentation Improvement Specialist
  • Preferred clinical experience with acute care experience at a large facility
  • Preferred experience with 3M360 Clinical Documentation and EPIC electronic medical record
  • Excellent communication and interpersonal skills; ability to communicate verbally and in writing with individuals of varying educational levels
  • Credible with Physician leadership
  • Significant financial and analytical skills
  • Word, Outlook, Excel PowerPoint experience preferred
  • Analytical skills necessary to clinically assess medical records required
15

Clinical Documentation Improvement Consultant Resume Examples & Samples

  • Revenue cycle assessments for hospitals, health systems, and diagnostic laboratories
  • Revenue cycle process improvement
  • Alignment and implementation of client/partner processes and Optum360 technology
  • Revenue cycle improvement / redesign
  • Reimbursement and managed care
  • Interim management (as applicable)
  • Provide revenue cycle management services to client/partners in all areas of revenue cycle which includes
  • 2+ years of experience in a director or supervisory role in an acute care setting
  • 3+ years of experience clinical documentation experience
  • 6+ years of experience working in a clinical role in a multi-facility health system
  • Expert in MS Word and Excel and Visio
  • Experience and comfort working at all levels of a health care organization
  • Ability to probe, analyze, synthesize and articulate complex subject matter so it can be easily understood
  • In-depth knowledge of the complete healthcare revenue cycle
  • Working knowledge of laboratory and hospital based IT systems
  • RN/BSN degree
  • Expert in Outlook and PowerPoint
16

Clinical Documentation Improvement Director Days Resume Examples & Samples

  • Graduation from a program of Nursing, BSN and/or Bachelors of Science in Health Information Management or related degree, Registered Health Information Administrator and/or Certified Coding Specialist certification
  • 8 years+ acute care experience with recent management or supervisory experience of clinical documentation program
  • Current RN licensure or obtain Florida License within 6 months or Registered Health Information Administrator or Certified Coding Specialist certification
17

Manager Clinical Documentation Improvement Resume Examples & Samples

  • Manages CDI department personnel and operations to include personnel management, education, training, work flow analysis, productivity, quality, and report management to ensure achievement of departmental goals and objectives
  • Facilitates appropriate clinical documentation reviews to support accurate assignment of diagnoses and procedure codes, severity of illness, risk of mortality, MCC/CC capture, appropriate POA assignment, PSI, HAC, and provider queries
  • Performs and/or monitors quality reviews to ensure compliance with regulatory requirements, accreditation standards, and industry best practices
  • Collaboratively works with coding, quality, care management, physician champions, and other key stakeholders to improve clinical documentation
  • Conducts data and root cause analysis and communicates clinical documentation opportunities and/or concerns to key stakeholders in a timely and effective manner
  • Contributes to CDI strategic planning and process improvement activities
  • Integrates Cleveland Clinic’s Improvement Model (CCIM) and tools into daily operations to drive best practices and outcomes (i.e. huddles, visual management tools, 4-blocker, return to green plan, A3, etc.)
  • Working with their director, reviews, revises, and/or implements departmental policies, procedures and/or guidelines
  • Monitors achievement of CDI key performance indicators and initiates and executes action plans as appropriate
  • Minimum three years of supervisory or management experience in a health care setting required
  • Health Information Management department experience preferred
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Manager, Clinical Documentation Improvement Resume Examples & Samples

  • Monitoring and Building CDI team
  • Oversee and act as resource for Clinical Documentation Improvement departments across Conifer Health including monitoring daily activity and completion of performance and metric reports
  • Test, interview, hire and retainCDI staff
  • Lead meetings with team leads and CDI l staff Account for timekeeping in all systems for all initiatives
  • Development of team goals and plans ensuring alignment with national goals and yearly evaluations
  • Improve Medical CMI throughout Conifer
  • Responsible for the supervision and coordination of CDI process including implementation and adherence to best practices and principles
  • CDI Subject Matter Expert
  • Knowledge of disease pathophysiology and drug utilization
  • Effective written and verbal communication skills including report writing and presentation skills
  • Ability to maintain an auditing and monitoring program as a means to measure query process
  • Skilled in performing quality assessment/analysis
  • Assess, coach, train and develop talent
  • Three (3) or more years’ experience in CDI
  • Preferred: Minimum: Two (2) years supervisory experience
19

Clinical Documentation Improvement Liaison Resume Examples & Samples

  • Coding Technical Skills - regulatory coding (ICD-10-CM, ICD-10-PCS, ICD-9-CM, MS-DRGs, POA Assignment) and associated reimbursement knowledge
  • Critical thinking - actively and skillfully conceptualizing, applying, analyzing, synthesizing or evaluating information gathered from, or generated by, observation, experience, reflection, reasoning or communication as a guide to belief and action
  • Effective Operational Decision Making - relating and comparing; securing relevant information and identifying key issues; committing to an action after developing alternative courses of action that take into consideration resources, constraints, and organizational values
  • Initiative – independently takes prompt proactive steps towards problem resolution
  • Stress tolerance – maintaining stable performance under pressure or opposition; handling stress in a manner that is acceptable to others and the organization
  • Planning and Organization - proactively prioritizes initiatives, effectively manages resources and keen ability to multi-task
  • Minimum 3 years' health care management/leadership experience required
  • Minimum 5 years' recent inpatient hospital coding experience required
20

Manager Clinical Documentation Improvement Resume Examples & Samples

  • Work with Revenue Cycle leadership to develop, implement, and oversee effective and consistent operational policies, processes, tools, and educational materials within all CDI functional areas
  • Manage the operational performance and productivity of the system-wide Clinical Documentation Improvement program against pre-defined policies and goals/targets
  • Collaborates with staff, leadership across the Revenue Cycle organization, clinical departments, and related stakeholders to identify and track trends in clinical documentation and resolve noted areas of improvement
  • Maintain a strong background in APR-DRGs, MS-DRGs, ICD-9 codes, ICD-10 codes, coding guidelines and coding clinics
  • Maintain a current working knowledge of Medicare/Medicaid rules and regulations along with knowledge of other diagnosis related group (DRG) payer sources
  • Maintain current working knowledge of CDI, present on admission (POA) and basic coding, as well as trends and developments in the area of CDI
  • Create a work environment for employees through team building, coaching, constructive feedback, work delegation, personal example and goal setting that encourage creativity, open dialogue on work issues, professional growth, and a consistent, high level of performance. Encourage and supports employee decision-making within their scope of responsibilities
  • Build strong relationships and facilitate productive communication between key Revenue Cycle stakeholders, including peer leaders of Revenue Cycle services and core support departments (e.g., human resources, business support services, finance, compliance)
  • Perform any special assignments as requested
21

Clinical Documentation Improvement Division Leader Resume Examples & Samples

  • 7+ years professional experience
  • Current RN license with Critical Care, OR, ER experience preferred
  • Current RHIA or RHIT or CPC (Certified Professional Coder) or CCS (Certified Coding Specialist)
  • If a foreign medical graduate, a MBBS required
22

Clinical Documentation Improvement Resume Examples & Samples

  • Review inpatient medical records for identified payor populations (i.e., Medicare, Medicaid, Managed Care etc.) as directed on admission and throughout hospitalization, analyzing clinical status of patient, current treatment plan and past medical history and identifies potential gaps in physician documentation
  • Ensure that clinical documentation reflects the level of service rendered to patients in complete, accurate and compliant with the regulations of the Center for Medicare and Medicaid Services
  • Utilize clinical knowledge toobtain appropriate documentation through extensive interaction with physicians, nursing, other patient caregivers and Health Information Management staff
  • Perform initial charts reviews and assign working DRG within 24 hours of admission, on the working days
  • Initiate quality of care measure process for required conditions from the initial chart review process. Identifies physician documentation issues/omissions/discrepancies and assists physicians with improving documentation in the medical records
  • Demonstrate good knowledge in clinical documentation improvement, serving as a resource and participating in problem-solving opportunities
  • Resolve inconsistent, conflicting and/or ambiguous documentation through compliant physician query process in at least 85% of the cases
  • Follow up with physicians to get resolution of all queries prior to patient’s discharge in 85% of the cases
  • Assist in the development of compliant diagnosis/DRG specific queries to aid physicians with proper and precise documentation
  • Maintain up to date working DRG and has clear strategies to effectuate improved quality of clinical documentation for all the select cases
  • Regularly participate in scheduled case management meetings and actively exchange information pertaining to clinical documentation, plan of care affecting coding and reimbursement
  • Take responsibility in addressing medical necessity issues through concurrent review process, initiating compliance with CORE measures before discharge and assisting in follow-up on queries and clarifications to physicians concurrently and retrospectively
  • Demonstrate working knowledge of information systems related to job duties
  • Effectively utilize documentation improvement communication tools
  • Demonstrate proficiency in utilization of computer based tools in retrieving and maintaining inpatient census data
  • Perform daily reviews with input into available system using appropriate screening tool to facilitate ongoing auditing, monitoring and corrective action within the Clinical Documentation Improvement (CDI) process
  • Assist Performance Improvement and Quality Departments in improving clinical documentation for compliance in quality of care measures (esp. Medicare CORE Measures) and other hospital quality metrics for specific charts/patient population
  • Maintain good rapport and cooperative relationships with medical staff, nursing staff &coding staff, approaching conflicts in a constructive manner. Help identify problems, offer solutions and participate in resolution
  • Foster respect for privacy by maintaining confidentiality in all phases of the work
  • Demonstrate knowledge of and perform the duties in accordance with the ethical and legal compliance standards as set by hospital policies and procedures, State and Federal Quality Improvement Organizations, Office of Inspector General (OIG), Centers for Medicare and Medicaid Services (CMS)
  • Contribute to ongoing department information sharing and promoting knowledge and skill development
  • Demonstrate knowledge of resource management in an effort to decrease resource consumption while adequately maintaining effective operations
  • Maintain current professional credential (s) related to clinical documentation improvement and submits a copy to Human Resources in a timely manner
  • Initiate & participate in formal and informal, required and voluntary continuing education opportunities; enhancing professional growth, maintaining CEU’s required for licensure and/or certification, and enabling adherence to changes in regulatory requirements
  • Educate all members of the patient care team on documentation guidelines on an ongoing basis
  • Consistently adheres to instructions from Superiors (Supervisor/Manager/Director etc) and follow the chain of command
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Clinical Documentation Improvement Resume Examples & Samples

  • Have sound knowledge and understanding of pathophysiology of disease processes and their management
  • Have knowledge of age-specific needs and elements of disease processes and related procedures
  • Understand care delivery documentation systems and related medical record documentation of patient’s care reflective of the severity of the patient’s condition
  • Have assertive personality traits to facilitate ongoing physician education
  • Have ability to work independently in a time oriented environment
  • Be computer literate and familiar with operation of basic office equipment
  • Be willing to learn and consistently take instructions from Superiors (Supervisor/Manager/Director etc.) whiles ensuring that the chain of command is followed within the department
  • Utilize clinical knowledge to obtain appropriate documentation through extensive interaction with physicians, nursing, other patient caregivers and Health Information Management staff
  • Perform initial chart reviews and assign working DRG within 24 hours of admission, on the working days
  • Demonstrate good knowledge in clinical documentation improvement and participate in problem-solving opportunities
  • Maintain good rapport and cooperative relationships with medical staff, nursing staff &coding staff, approaching conflicts in a constructive manner
24

Director Clinical Documentation Improvement Altamonte Springs Resume Examples & Samples

  • Effective oral and written communication skills, with the ability to articulate complex information in understandable terms to all levels of staff
  • Effective computer skills, particularly Microsoft Office Outlook, Word, Excel
  • Ability to work in a matrix-management environment to achieve organizational goals
  • High degree of clinical knowledge and hospital coding knowledge (i.e., APR-DRG, MS-DRG, Medicare, Medicaid & Managed Care)
  • Ability to establish and manage complex and effective relationships
  • Customer-focused attitude and ability to work proactively and efficiently with appropriate urgency
  • Up-to-date knowledge of ICD-10 mandate and the impact of code set transition (e.g., potential impact on data quality for prospective payments, utilization, and reimbursement)
  • At least seven to ten years’ acute hospital clinical experience
  • Ten plus years of experience in a clinical documentation improvement program
  • Five years progressively responsible leadership experience
  • At least five years of experience as a CDI director or manager in a large acute care hospital setting
  • Master’s degree in Nursing, business or health related field (preferred)
  • Current, valid State of Florida license as a registered professional nurse
  • Certified Clinical Documentation Specialist (CCDS) or Certified Coding Specialist (CCS) credential (preferred)
  • Ensure standardization throughout the existing CDI programs according to industry leading practices. Develop and maintain organization-wide policies and guidelines that provide structure for the individual CDI programs
  • Develop an active, collaborative interface and structure with Florida Hospital Medical Staff
  • Organize process improvement/committee on a clinical or product line basis to address documentation improvement opportunities. Provides staff support services to such committees
  • Contribute to the design and development of a clinical documentation improvement program in coordination with hospital and division leadership
  • Facilitate appropriate clinical documentation to support diagnosis capture
  • Facilitate modifications to clinical documentation to ensure accurate depiction of the level of clinical services and patient severity to support appropriate reimbursement and capturing of clinical severity for the level of service rendered to all hospitalized patients
  • Oversees and maintains accountability for compliance with all regulatory standards and requirements
  • Develops and meets department budgets. Appropriately manages resources
  • Collaborate with peers regarding department budget and operational plan development to maintain fiduciary responsibility and achieve greater financial performance
  • Oversees expense including resource utilization for supplies and staff
  • Oversees relationship management with payers and network providers
  • Establishes and maintains communication with Financial Planning and Revenue Cycle Business Analytics team
  • Provide strategic planning and direction for the development and enhancement of CDI program services through the National CDI Center of Excellence. Develop collaborative relationships with internal resources, consultants, auditors, and physician champions to develop and achieve the established plan
  • Promotes collaboration and removes obstacles to teamwork across the organization
  • Work with FH leadership to implement a CDI governance structure responsible for achieving clinical and operational excellence, and expected deliverables in relation to the CDI program at FH Provide leadership support and integrate with other departments/programs such as HIM/Coding, and clinical care departments
  • Develop a meaningful scorecard, dashboard metrics, peer group comparisons, and service specific data that are actionable. Implement tracking tools to benchmark against best practices, to maintain forward momentum, and to establish timelines for actions
  • Collaborates in the development of programs, initiatives and workflows, which provide alignment with education for internal customers to support clinical documentation guidelines
  • Supports, promotes, and encourages Florida Hospital community efforts such as canned food drive, back pack for kids, adopt-a-family, United Way, and all other related activities
  • Actively participates and supports national, state, and local professional associations
  • Responsible for recruiting and providing support, guidance and mentorship to Clinical
  • Documentation Improvement team to ensure succession planning. Responsibility includes one manager who is directly responsible for and supports a total of 40 FTE’s. Manage department labor tracking and budget in accordance with organizational policies and in conjunction with AVP
  • Provides leadership and guidance of staffing resources to ensure compliance with department standards; ensuring hours are flexed and over time is avoided as necessary