Clinical Documentation Improvement Specialist Resume Samples

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NC
N Cronin
Nathanial
Cronin
251 Zachery River
San Francisco
CA
+1 (555) 209 8278
251 Zachery River
San Francisco
CA
Phone
p +1 (555) 209 8278
Experience Experience
New York, NY
Clinical Documentation Improvement Specialist
New York, NY
Ratke Group
New York, NY
Clinical Documentation Improvement Specialist
  • Development and delivery of Physician, Coder and Clinical Documentation Improvement Specialist (CDIS) education through a variety of modalities
  • Performs 100% Comprehensive concurrent coding quality reviews for providers in each market for all CCM lines of business (NP, PA, MD)
  • Performs other work related duties as assigned or requested
  • Providing coders, senior leadership and facility personnel orientation to documentation improvement activities
  • Assist leadership in researching literature and industry trends to identify new methods development and overall documentation enhancement
  • Assist leadership in the analysis and trending of statistical data for specified patient populations to identify opportunities for improvement
  • Performs 100% Comprehensive concurrent coding quality reviews for providers in each market for all CPM lines of business (NP, PA, MD)
Philadelphia, PA
Clinical Documentation Improvement Specialist Rehab
Philadelphia, PA
Homenick, Schultz and Kirlin
Philadelphia, PA
Clinical Documentation Improvement Specialist Rehab
  • Proactively develops a reciprocal relationship with the HIM Coding Professionals
  • Work Location: St. Mary Medical Center (Long Beach, CA)
  • Provides face-to-face educational opportunities with physicians on a daily basis
  • Utilizes only the Optum360 approved clarification forms
  • Ensures effective utilization of Midas or Optum® CDI 3D Technology to document all verbal, written, electronic clarification activity
  • Provides feedback and works with Clinical Documentation Improvement Educator to develop targeted education and training to improve accuracy
  • Collaborate with the Corporate Manager of Clinical Documentation Improvement to develop/upkeep efficiencies/synergies within the CDI dept
present
Boston, MA
Clinical Documentation Improvement Specialist K Sign On
Boston, MA
Walter Group
present
Boston, MA
Clinical Documentation Improvement Specialist K Sign On
present
  • Performs regular rounding with unit-based physicians and provides Working DRG lists to Care Coordination
  • Provides complete follow through on all requests for clarification or recommendations for improvement
  • Leads the development and execution of physician education strategies resulting in improved clinical documentation
  • Provides timely feedback to providers regarding clinical documentation opportunities for improvement and successes
  • Coordinates and conducts regular meeting with HIM Coding Professionals to reconsolidate DRGs, monitor retrospective query rates and discuss questions related to Coding and CDI
  • Provides expert level leadership for overall improvement in clinical documentation by providing proficient level review and assessment, and effectively articulating recommendations for improvement, and the rational for the recommendations
  • Actively engages with Care Coordination and the Quality Management teams to continually evaluate and spearhead clinical documentation improvement opportunities
Education Education
Bachelor’s Degree in Flexibility
Bachelor’s Degree in Flexibility
Liberty University
Bachelor’s Degree in Flexibility
Skills Skills
  • Have the ability to maintain concentration with attention to detail even in areas containing multiple levels of distraction
  • Strong medical skills and knowledge
  • Advanced knowledge of Medicare Part A and familiar with Medicare Part B
  • Ability to multitask
  • Strong case management skills
  • Highly organized
  • Excellent communication skills
  • Proficient with MS Office applications
  • Strong clinical skills including understanding of clinical disease process, pathophysiology and treatment plans
  • Ability to adapt to multiple and changing priorities
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7 Clinical Documentation Improvement Specialist resume templates

1

Clinical Documentation Improvement Specialist Resume Examples & Samples

  • Through interaction with physicians, nursing staff, medical records coding staff/compliance specialists and other healthcare providers, clinical documentation analysts facilitate modifications to clinical documentation ensuring accurate depiction of the level of clinical services, reason for admission, patient severity, risk of mortality, severity of illness and conditions present on admission
  • Review medical record documentation for quality and possess ability to convey deficiencies to house staff and attending physician for resolution
  • Compile and document chart findings in dedicated CDI database on a daily basis
  • Communicate with and educate members of the patient care team (physicians and advanced practice providers) and others on the clinical documentation concepts on an ongoing basis
  • Participation on select committees and providing educational programs as necessary
  • 3 years of relevant experience and appropriate certifications. For Nurses case management or utilization review and acute care clinical experience is preferred
2

Clinical Documentation Improvement Specialist Resume Examples & Samples

  • Communicate to the provider specific targeted quality measures that have consistently not been meet for the current year. In addition, will identify and provide feedback on targeted chronic disease adherence standards that need to be ordered/obtained for the current year via EMR notification/alert
  • Ability to facilitate, webinars, and workshops to elicit requirements and provide educational opportunities
  • Continuously develop and expand knowledge through on-the-job learning opportunities, and professional literature, which allows the ability to position industry experience as they pertain to physician's needs and requirements
  • Maintain ongoing communication with physicians regarding engagement status, issues, findings and recommendations
  • Ensure timeliness, quality and results of all project deliverables
3

Clinical Documentation Improvement Specialist Resume Examples & Samples

  • Communicate verbally and via email with physicians often, discussing and educating diagnosis and documentation
  • Process discharges by updating the Severity/Complexity of Services Worksheet to reflect any changes in status, procedures/treatments, and conferring with physician to finalize diagnosis
  • At least 1 year experience working as inpatient Clinical Documentation Specialist
  • Knowledge of clinical documentation guidelines and CDI program implementation experience
  • Knowledge of medical terminology, ICD-9-CM, ICD-10 CM and ICD-10 PCS
  • Knowledge of CDI strategies and documentation needs
  • Associate’s or Bachelor's Degree in a relevant field or combination of equivalent education and experience
  • 3+ years of clinically well-rounded medical or surgical acute care nursing experience
4

Clinical Documentation Improvement Specialist Resume Examples & Samples

  • Provides expert level review of inpatient clinical records within 24-48 hours of admit; identifies gaps in clinical documentation that need clarification for accurate code assignment to ensure the documentation accurately reflects the severity of the condition and acuity of care provided
  • Conducts daily follow-up communication with providers regarding existing clarifications to obtain needed documentation specificity
  • Proactively develops a reciprocal relationship with the HIM Coding Professionals
  • Engages and consults with Physician Advisor /VPMA when needed, per the escalation process, to resolve provider issues regarding answering clarifications and participation in the clinical documentation improvement process
  • Actively engages with Care Coordination and the Quality Management teams to continually evaluate and spearhead clinical documentation improvement opportunities
  • Current RN License or Medical School Graduate
  • 2+ years acute care hospital clinical experience
  • Previous experience in case management and / or critical care
5

Clinical Documentation Improvement Specialist K Sign On Resume Examples & Samples

  • Ensures effective utilization of Midas or Optum® CDI 3D Technology to document all verbal, written, electronic clarification activity
  • Coordinates and conducts regular meeting with HIM Coding Professionals to reconsolidate DRGs, monitor retrospective query rates and discuss questions related to Coding and CDI
  • Current RN License with 5+ years of inpatient acute care experience OR Medical School Graduate with Clinical Documentation Improvement experience
  • Basic proficiency using a PC in a Windows environment, including Microsoft Word, Excel, and Electronic Medical Records (Cerner is preferred)
6

Clinical Documentation Improvement Specialist Resume Examples & Samples

  • 3+ years acute care hospital clinical experience
  • Must have proficiency using a PC in a Windows environment, including Microsoft Word, Excel, Power Point, Electronic Medical Records (Cerner is preferred) and CAC technologies
  • Must have remote CDI experience
  • Strong understanding of clinical, HIM, Quality and Case Management workflow
7

Clinical Documentation Improvement Specialist Rehab Resume Examples & Samples

  • *Work Location: St. Mary Medical Center (Long Beach, CA)***
  • Actively communicates with providers at all levels, to clarify information and to communicate documentation requirements for appropriate diagnoses based on severity of illness and risk of mortality
  • Performs regular rounding with unit-based physicians and provides Working DRG lists to Care Coordination
  • Provides complete follow through on all requests for clarification or recommendations for improvement
  • Leads the development and execution of physician education strategies resulting in improved clinical documentation
  • Utilizes only the Optum360 approved clarification forms
  • Experience in Clinical Documentation Improvement
  • Current certification as a CCDS, CDIP or CCS
  • Clinical Experience in an acute inpatient rehab unit
8

Clinical Documentation Improvement Specialist Resume Examples & Samples

  • Conducts initial concurrent review process for all selected admissions to initiate tracking process, documenting findings on DRG worksheets, and identification of other key pathway or quality indicators as appropriate; acts as liaison for documentation efficiencies with Health Information Management, Case Management, Ancillary Departments, Physicians, Nursing and Administration
  • Demonstrates knowledge of DRG payor issues, appropriate DRG assignment alternatives, clinical documentation requirements, and referral policies and procedures; improves the overall quality and completeness of clinical documentation by performing record reviews using clinical documentation guidelines which then supports the accuracy and completeness of clinical information used for measuring and reporting physician and medical center outcomes
  • Interacts and communicates with Physician staff daily as needed – educating them in the process of clarifying documentation in the medical record; conducts follow up reviews of clinical documentation to ensure points of clarification have been recorded in the patient’s chart
  • Maintains the DRG Worksheet to include abstraction of patient clinical findings relevant to assign an ongoing working DRG, Physician Documentation Request/interactions and visit frequency; in collaboration with the physician and coder, identifies and records principal and secondary diagnosis, principal procedures, and assigns a working DRG
  • Identifies needs to clarify documentation in records and initiates communication with physician by utilizing the appropriate “query” tools in order to capture the documentation in the medical record that supports patient’s severity of illness; performs a thorough chart review to identify co morbidities/complications; documents all known MCC’s and CC’s appropriately on the DRG worksheet
  • Demonstrates an understanding of the importance of and makes an effort to capture ALL secondary diagnoses (for profiling purposes), including those that do not directly affect the DRG assignment; reviews coder feedback on completed worksheets and individual internal tracking system reports as a means of continuous self evaluation; discusses any issues or concerns with the Director
9

Clinical Documentation Improvement Specialist Resume Examples & Samples

  • Facilitating and obtaining appropriate physician documentation for any clinical conditions or procedures to support the appropriate severity of illness, expected risk of mortality, and complexity of care of the patient- Having proficiency regarding clinical documentation requirements, DRG assignment, and clinical conditions or procedures
  • Educating members of the patient care team regarding documentation guidelines, including attending physicians, allied health practitioners, nursing, and case management
  • Performing quality assurance functions for CDI team, prepares and delivers education as appropriate, and monitors, trends, and educates as needed
  • Completing initial reviews of patient records within 24–48 hours of admission for a specified patient population to: (a) evaluate documentation to assign the principal diagnosis, pertinent secondary diagnoses, and procedures for accurate DRG assignment, risk of mortality, and severity of illness; and (b) initiate a review worksheet
  • Conducting follow-up reviews of patients every 2–3 days or as appropriate to support and assign a working or final DRG assignment upon patient discharge
  • Querying physicians regarding missing, unclear, or conflicting health record documentation by requesting and obtaining additional documentation within the health record when appropriate
  • Educating physicians and key healthcare providers regarding clinical documentation improvement and the need for accurate and complete documentation in the health record
  • Collaborating with case managers, nursing staff, and other ancillary staff regarding interaction with physicians on documentation and to resolve physician queries prior to patient discharge
  • Participating in the analysis and trending of statistical data for specified patient populations to identify opportunities for improvement
  • Assisting with preparation and presentation of clinical documentation monitoring/trending reports for review with physicians and hospital leadership. Educates members of the patient care team regarding specific documentation needs and reporting and reimbursement issues identified through daily and retrospective documentation reviews and aggregate data analysis
  • Partnering with the coding professionals to ensure accuracy of diagnostic and procedural data and completeness of supporting documentation to determine a working and final DRG, severity of illness, and/or risk of mortality
  • Reviewing and clarifying clinical issues in the health record with the coding professionals that would support an accurate DRG assignment, severity of illness, and/or risk of mortality
  • Performing quality review audits of CDI team
  • Preparing and presenting educational as identified via the CDI QA process Monitors and trends performance of CDI Specialists and recommends performance improvement steps/education as appropriate
10

Risk Adjustment Clinical Documentation Improvement Specialist Resume Examples & Samples

  • Assist with execution of Internal Risk Adjustment Coding Review programs
  • Performs quality audits on vendor charts as well as Care Delivery coding teams as needed
  • Provides support and assists Care Delivery with various coding initiatives as needed
  • Ensure that Optum Coding Guidelines are consistently applied in all processes
  • Provides input and valuable feedback on audit results
  • Provide ICD10 - CM coding training, as it relates to HCC coding, as requested
  • Develops relationships with Care Delivery and communicates guidelines and requirements of Risk Adjustment Payment System to ensure correct coding and documentation
  • Cross - functional collaboration with multiple teams and functions
  • HS Diploma or higher or significant equivalent work experience
  • Coding Certification required (CPC, CCS, CCS-P, or RHIT; CPC - A or CCA designation is not acceptable)
  • 4+ years’ experience ICD - 9 / 10 coding, preferably in a Managed Care setting, with strong attention to detail and high accuracy rate
  • 2+ years’ coding experience in a provider’s office, inpatient setting or a Medicare Advantage health plan setting – can be combined experience
  • 2+ years’ Medicare Risk Adjustment experience
  • 2+ years’ Provider education experience – communicating directly with providers
  • Compliant Physician query experience/knowledge
  • 1+ year experience in a coding auditor role
  • Proficient knowledge of CMS - HCC model and guidelines
  • ICD - 10 - CM proficient
  • Knowledge of HEDIS / STARS
  • Normal schedule M - F 8am - 5pm, ability to work a flexible schedule to meet business needs and accommodate meetings in various time zones as needed
  • Ability to work across a matrix environment
  • Microsoft Office proficiency (Word, Excel, PowerPoint & Outlook)
  • Up to 75% travel (local, non - local meetings)
  • Must be able to continuously meet the requirements for a telecommuter, i.e. live in a location that can receive a UnitedHealth Group approved high speed internet connection, have a secure designated office space to maintain PHI, meet or exceed all performance expectations
  • CRC (Certified Risk Coder) in addition to required coding certification
  • ICD - 10 - CM trainer
  • 1+ years HEDIS / STARS experience
  • Previous experience with WebEx or similar virtual meeting tools
  • Previous experience with data analysis and reporting
  • Previous experience using diagnosis coding data and trends to identify training opportunities
11

Risk Adjustment Clinical Documentation Improvement Specialist Resume Examples & Samples

  • 4+ years’ experience ICD-9 / 10 coding, preferably in a Managed Care setting, with strong attention to detail and high accuracy rate
  • Knowledge of HEDIS /S TARS
  • Up to 75% travel (local)
  • ICD-10 - CM trainer
  • 1+ years HEDIS/STARS experience
12

Clinical Documentation Improvement Specialist Resume Examples & Samples

  • CDI Specialist must display teamwork and commitment while performing daily duties
  • Travel may be required to meet the needs of the facilities
  • Advanced knowledge of Medicare Part A and familiar with Medicare Part B
  • Intermediate knowledge of disease pathophysiology and drug utilization
  • Intermediate knowledge of MS-DRG classification and reimbursement structures
  • Regular and reliable attendance and time reporting per Conifer Telecommuting program requirements
  • Preferred: Acute Care nursing and/or Foreign trained relevant experience
  • One (1) to two (2) years experience
  • Graduate from a Nursing program, BSN, and/or medical school graduate
  • Must be able to efficiently use computer keyboard and mouse
  • Good visual acuity
13

Clinical Documentation Improvement Specialist Resume Examples & Samples

  • Performs concurrent review of record to determine complete, accurate documentation of patient condition and treatment
  • When appropriate, update working DRG
  • Promotes and obtains appropriate documentation for any clinical conditions or procedures to support the appropriate severity of illness (SOI), expected risk of mortality (ROM) and complexity of care of the patient through extensive interaction with practitioners
  • Queries practitioners concurrently regarding missing, unclear, or conflicting health record documentation by obtaining additional documentation within the health record as needed
  • Provides ongoing education and information to practitioners regarding documentation opportunities. Promotes related education to others such as allied health professionals, administration, Utilization Review, Care Coordination specific to documentation and its effect on severity of illness, risk of mortality, case mix index, reimbursement, and data reporting
  • Collaborates with Health Information Management coders to reconcile working versus final coded DRG. Collaboratively works with interdisciplinary teams including, but not limited to, physicians, mid-level providers, nurses, Utilization Review staff, and Care Coordination
  • Formulates, interprets, and analyzes data relative to Opportunities to improve documentation practices including impact to Diagnosis Related Group, Risk of Mortality, Severity of Illness and ultimately, Physician profiles
  • Associate’s Degree from accredited Nursing program
  • 5 Years of Experience in Nursing
14

Clinical Documentation Improvement Specialist Resume Examples & Samples

  • Practices and adheres to the “Code of Conduct” philosophy and “Mission and Value Statement”
  • Obtains and promotes appropriate clinical documentation through extensive interaction with physicians, nursing staff, and other patient caregivers to ensure that the documentation of the level of service rendered to the patient and the patient’s clinical complexity is complete and accurate
  • Reviews medical records and identifies potential gaps in clinical documentation
  • Performs a thorough chart review to identify that the Principal diagnosis, present on admission (POA) indicators and co-morbidities/complications are documented appropriately
  • Assigns concurrent MS-DRGs for identified populations by conducting initial and re-reviews Queries physicians using approved query forms for missing, unclear, or conflicting documentation by requesting and obtaining additional documentation within the health record to obtain accurate and complete documentation that supports the severity of patient illness and risk of mortality
  • Interacts with physicians to resolve queries prior to patient discharge
  • Collaborates with case managers, nursing staff, and other ancillary staff to help resolve physician queries prior to patient discharge
  • Educates physicians and key healthcare providers regarding clinical documentation improvement and the need for accurate and complete documentation in the health record; provides formal and informal in-services as needed to physicians and ancillary staff
  • Participates in the analysis and trending of statistical data to identify opportunities for improvement
  • Identifies strategies for work process changes that facilitate complete, accurate clinical/physician documentation
  • Documents reviews and other pertinent information concurrently by the established deadlines
  • Documents reviews and other pertinent information post discharge by the established deadlines
  • Works closely with designated Health Information Service Center (HSC) coding staff to assure documentation of discharge diagnoses and any co-existing co-morbidities are a complete reflection of the patient’s clinical status and care
  • Reviews HSC coding feedback as a means of continuous education and self-evaluation
  • Reviews HSC coding post discharge query trending as a means of concurrent physician interaction opportunities
  • Demonstrates ongoing knowledge of clinical requirements and coding standards for evaluation of medical record documentation
  • Completes all assigned education by the established deadlines
  • Provides coverage for other CDI staff
  • Assists with training CDI staff
  • Maintains the ability to be flexible and prioritize daily responsibilities
  • Building and Maintaining Strategic Working Relationships – develops collaborative relationships to facilitate the accomplishment of work goals; possesses excellent interpersonal skills in building, negotiating and maintaining crucial relationships
  • Communication - communicates clearly, proactively and concisely; listens actively; alters communication style as appropriate; writing and speaking skills indicate good grammar style and tone
  • Teamwork – balances team and individual responsibilities; objective and open to other’s views; gives and welcomes feedback; contributes to positive team spirit; puts success of team above own interest
  • Customer Service – adheres to the Customer Service expectations and philosophy established at physical work location; shows respect for the customer; anticipates/responds quickly to customer needs/concerns; keeps commitments
  • Proficient clinical assessment skills, including understanding of disease processes and pathophysiology
  • Thorough understanding of inpatient coding guidelines and physician documentation impact
  • Working knowledge of the inpatient prospective payment system (IPPS)
  • Policies & Procedures - articulate knowledge and understanding of organizational policies, procedures and systems
  • PC skills - demonstrate proficiency in software applications as required
15

Clinical Documentation Improvement Specialist Resume Examples & Samples

  • Registered Nurse with current D.C. license or BSN preferred
  • Minimum of 5 years recent clinical experience in an acute care setting (i.e. Critical Care, Medical/Surgical or Emergency Department nursing preferred)
  • Previous experience with coding classification systems and DRG guidelines preferred
  • Excellent critical thinking skills, problem solving and deductive reasoning required, must be detail oriented
  • Must be dependable and self-directed
  • Working knowledge of Medicare reimbursement system and coding structures, preferred, not required
  • History of positive nurse-physician relationships and ability to maintain and improve going forward
16

Clinical Documentation Improvement Specialist Resume Examples & Samples

  • Performs concurrent coding quality reviews for newly hired and contracted providers (NP, PA, MDs) of 100% of all records until the provider achieves 95% accuracy rate
  • Performs 100% Comprehensive concurrent coding quality reviews for providers in each market for all CPM lines of business (NP, PA, MD)
  • Evaluates documentation to ensure that diagnosis coding is supported and meets specificity requirement to support clinical indicators, HEDIS and STARS quality measures
  • Queries providers regarding missing, unclear, or conflicting health record documentation by requesting and obtaining additional documentation within the heath record
  • Provides feedback and works with Clinical Documentation Improvement Educator to develop targeted education and training to improve accuracy
  • Develops relationships with clinical providers and communicates coding and documentation guidelines and requirements of the Risk Adjustment program to ensure correct coding and documentation
  • Maintains a 96% quality audit accuracy rate
  • Performs the minimum number of coding quality reviews consistent with established departmental goals
  • Takes direction and guidance from Supervisor of the Risk Adjustment Coding and Documentation Improvement Specialist and the Manager of the Risk Adjustment Coding and Documentation Improvement Program
  • Coding Certification from AACP or AHIMA professional coding association (CPC, CPC-H, CPC-P, RHIT, RHIA, CCS, CCS-P) or RN/LPN with ability to obtain coding certification from AHIMA or AAPC within 12 months of hire
  • 3 years active coding experience with ICD diagnosis coding
  • 1 year experience as ICD coding Auditor
  • Working knowledge of ICD diagnosis coding rules and guidelines
  • Requires strong verbal / written communication and interpersonal skills
  • Ability to effectively report deficiencies with a recommended solution in oral and / or written form
  • Proficiency with Microsoft Office applications to include Word, Excel, PowerPoint and Outlook
  • Experience with Risk Adjustment / HCC Coding Model
  • Certification as Certified Risk Adjustment Coder
  • Experience or Certification as Clinical Documentation Improvement Specialist
  • Working knowledge of CPT / Evaluation and Management guidelines
  • Working Knowledge of CMS Risk Adjustment and HCC Coding Process
17

Clinical Documentation Improvement Specialist Resume Examples & Samples

  • *Work Location: St. Joe’s Medical Center in downtown Phoenix, AZ***
  • Must have proficiency using a PC in a Windows environment, including Microsoft Word, Excel, Power Point and Electronic Medical Records
  • BSN degree or equivalent preferred
  • CAC experience (Computer Assistant Coding)
18

Clinical Documentation Improvement Specialist Resume Examples & Samples

  • Performance of inpatient medical record audits
  • Issuance of compliant, CHS-approved, best-practice physician documentation clarification requests
  • Tracking and reporting of CDIS activities
  • Development and delivery of Physician, Coder and Clinical Documentation Improvement Specialist (CDIS) education through a variety of modalities
  • Providing coders, senior leadership and facility personnel orientation to documentation improvement activities
19

Clinical Documentation Improvement Specialist Resume Examples & Samples

  • *$5,000 sign on bonus***
  • Provides expert level review of inpatient clinical records within 24-48 hours of admit; identifies gaps in clinical documentation that need clarification for accurate code assignment to ensure the documentation accurately reflects the severity of the patient condition and acuity of care provided
  • Utilizes only the facility/Optum 360 approved forms, whether paper or electronic
  • Steers the development and implementation of education plans for the interdisciplinary care team to promote accurate and complete documentation in the medical record
  • Engages and consults with Physician Advisor when needed to resolve provider issues regarding answering clarifications and participation in the clinical documentation improvement process
  • Actively engages Case Management and RAC committee to continually evaluate and spearhead clinical documentation improvement opportunities to reduce denials and support medical necessity
  • 5+ years as an RN in an acute care hospital setting OR Medical Graduate with CDI experience, and 2 years of clinical experience in the hospital setting
  • BSN/MSN degree
20

Clinical Documentation Improvement Specialist Resume Examples & Samples

  • Must posses in-depth knowledge of anatomy and physiology, medical terminology, reimbursement principles, health record content, sequencing of diagnoses, and the use of coding software
  • A trainee is not acceptable for this job due to the complex nature and specialty knowledge-base associated with coding requirements/guidelines
  • A CHS pre-employment coding test must be taken with preferred pass rate of 80%
21

Clinical Documentation Improvement Specialist Resume Examples & Samples

  • Assigns concurrent MS-DRGs for identified populations by conducting initial and re-reviews
  • Queries physicians using approved query forms for missing, unclear, or conflicting documentation by requesting and obtaining additional documentation within the health record to obtain accurate and complete documentation that supports the severity of patient illness and risk of mortality
  • 3-5 years of experience in Critical Care nursing OR 3-5 years in inpatient coding
22

Travel Clinical Documentation Improvement Specialist Resume Examples & Samples

  • Conducts initial and extended-stay concurrent review on selected admissions and documents findings in (insert document/module here - e.g., CDIS module)
  • Identifies co-morbidities and complications and documents appropriately
  • Queries the medical staff and other clinical caregivers as necessary via written/verbal communication to obtain accurate and complete documentation
  • Identifies potential quality, severity of illness, risk of mortality, hospital/physician profiling, and reimbursement issues or missing documentation
  • Communicate documentation issues and trends, and reports them to the appropriate manager per hospital reporting requirements
  • Makes an effort to capture all potential secondary diagnoses
  • Act as the liaison between clinical care providers and coding professionals
  • Identifies documentation issues and trends, and reports them to the appropriate manager per hospital reporting requirements
23

Clinical Documentation Improvement Specialist Resume Examples & Samples

  • 5 years of direct critical care nursing experience required
  • Hospital Coding experience strongly desired
  • Previous CDI experience preferred
  • Coding Certificate or CCDIS certification is preferred
24

Clinical Documentation Improvement Specialist Resume Examples & Samples

  • Minimum of five years direct clinical nursing experience in Pediatrics required
  • Clinical experience in NICU and PICU preferred
  • Current FL RN License preferred. If you do not have a FL RN License one MUST be obtained before you can start
25

Clinical Documentation Improvement Specialist Resume Examples & Samples

  • Initiate and follow through with the process for all RAC and Third Party Payor denials at every level and review all denials with direct report for plan/strategy for appeal
  • Involve appropriate physicians in the appeal process expanding into the preparation for ALJ and DRA
  • Follow up Third Party Payor responses to all appeals as appropriate and update RAC and Third Party Payor denial logs and MIDAS as appropriate
  • Communicate denial issues with site HIM/CDIP Department and patient accounts
  • Identify RAC no appeal cases and enter in No appeal Corrective Action Log for quarterly submission
  • Continuously evaluates the quality of clinical documentation to identify incomplete or inconsistent documentation for inpatient encounters that impact the code selection and resulting DRG groups and payment. 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 documentation improvement
  • Provides feedback to HIM management staff and CDI leadership regarding opportunities for documentation improvement, and participates with the planning and development of educational programs directed towards improving documentation
  • Participates in education programs to maintain up to date coding skills
  • Bachelors of Science in Nursing
  • Current NYS License. CCDS Preferred
  • Proficient computer skills for Windows Microsoft Office Applications (Word, Excel, Power Point)
  • Five years clinical experience in Acute Hospital setting. CDI chart review skills with ICD- 10 CM/PCS coding experience. Knowledge of Federal Rules and Regulations. In patient hospital billing preferred
  • Multitasking, excellent communication and critical thinking skills
26

Clinical Documentation Improvement Specialist Resume Examples & Samples

  • RN, BSN with a minimum of three years’ experience in nursing or other clinical area of an acute care facility
  • Strong clinical skills including understanding of clinical disease process, pathophysiology and treatment plans
  • Experience working with an EHR, preferably Cerner Millennium
  • Effective interpersonal skills in order to interact effectively with physicians and all levels of hospital personnel
  • Organization and prioritization skills
  • CDIS certification
  • Emergency or critical care nursing background
  • Experience working with Cerner Millennium
27

Medical Record Technician Clinical Documentation Improvement Specialist Resume Examples & Samples

  • *Refer to the required documents section to ensure a complete application packet is provided***
  • Ability to interpret and analyze all information in a patient's health record, including laboratory and
  • Knowledge of coding rules and requirements to include clinical classification systems (such as current versions of ICD and CPT), complication or comorbidity/major complication or comorbidity (CC/MCC), Medicare Severity Diagnosis Related group (MS-DRG) structure, and Present on Admission(POA) indicators
  • *Note: Education cannot be substituted at the GS-9 level ***
28

Medical Record Technician Clinical Documentation Improvement Specialist Resume Examples & Samples

  • Six months of experience that indicates knowledge of medical terminology and general understanding of the health record and one year above high school with a minimum of 6 semester hours of health information technology courses
  • Successful completion of a course for medical technicians, hospital corpsmen, medical service specialists, or hospital training obtained in a training program given by the Armed Forces or the U.S. Maritime Service under close medical and professional supervision may be substituted on a month-formonth basis for up to six months of experience provided the training program included courses in anatomy, physiology, and medical record techniques and procedures. Also requires six additional months of experience that indicates knowledge of medical terminology and general understanding of the health record
  • Selecting and assigning codes from current version of one or more coding systems, including International Classification of Diseases (ICD-10), Current Procedural Terminology (CPT), and Healthcare Common Procedure Coding Systems (HCPCS)
  • Determining correct codes for routine, and/or new or unusual diagnoses and procedures not clearly listed in ICD, CPT, and HCPCS
  • Identifying the principal diagnosis, reason for admission, and significant complications and/or commodities as well as operating room procedures to assure proper Diagnosis Related Group (DRG) assignment
  • Assuring the maintenance and accuracy of diagnostic and procedural statistics for this facility, as well as optimum appropriate reimbursement under our Resource Allocation Methodology, Performance Measures, and third party payers, by coding of diagnoses and procedures using the required classification systems
  • Reviewing and screening the entire medical record to abstract medical, surgical, laboratory, pharmaceutical, demographic, social and administrative data from the medical recording a timely manner
  • Ensuring procedures are sequenced correctly, and coded in an accurate and ethical manner for optimum reimbursement
  • Knowledge of coding and documentation concepts, guidelines, and clinical terminology
  • Knowledge of anatomy and physiology, pathophysiology, and pharmacology
29

Clinical Documentation Improvement Specialist Resume Examples & Samples

  • Familiar with DRG’s and coding guidelines and how documentation impacts DRG assignment
  • RN Background required
  • One year minimum experience as a Clinical Documentation Improvement Specialist required
  • Proven ability to develop material and give presentations to small and large groups is required
  • CDI competency test with score above 80% required
  • Able to acquire CCDS certification after 2 years of CDI practice
  • CCS preferred
30

Clinical Documentation Improvement Specialist Resume Examples & Samples

  • Direct review of patient charts to audit clarity and full reflection of severity in care team documentation w consideration of CMS coding guidelines
  • Provide clinical care teams with ongoing education and training on current trends in documentation and coding
  • Collaborate with the Corporate Manager of Clinical Documentation Improvement to develop/upkeep efficiencies/synergies within the CDI dept
  • Enter clinical review data and related anticipated follow-up in Allscripts ECIN and/or PENN Chart (future state) to truthfully demonstrate current state discovered via chart review, discovery of qualities needing further provider clarification, abstraction of clinical indicators, and the assignment of Initial DRG and Working DRG
  • Generate compliant queries and non-leading clinical conversation w regard to requesting further specification and/or diagnostic clarity and/or clinical diagnostic significance and severity
  • Ensure that the concurrent inpatient clinical documentation accurately reflects severity of illness and intensity of service using the above noted compliant query system
  • Ensure the present on admission (POA) status of clinical conditions/diagnoses are charted appropriately within defined regulatory timeframes
  • Assign a working MS-DRG upon initial admission review, and communicate with Physician or designee requesting appropriate documentation
  • Ongoing concurrent chart review, identification of complications and co-morbidities, collaboration with team regarding improving documentation
  • Maintain strict HIPPA compliance and confidentiality in reference to all information reviewed and/or discussed
  • Maintains responsibility for professional development by participating in workshops, conferences, and/or in-services and maintains appropriate records of participation
  • Proficient in negotiating complex systems to effect positive change
  • Ability to interpret, adapt, and apply guidelines and procedures
  • Ability to analyze complex clinical scenarios and apply critical thinking. Extensive knowledge of reimbursement systems
  • Extensive knowledge of federal, state, and payer-specific regulations and policies pertaining to documentation and coding
  • Extensive knowledge of treatment methodology, patient care assessment, data collection techniques and coding classification systems is necessary
  • Serve as a resource on DRG issues
  • RHIA RHIT and CCS certifications preferred
  • An advance degree can be substituted for a PA RN license. One or the other is required
  • Clinical experience with knowledge of Medicare reimbursement system& coding structures is preferred
  • High level of creativity, judgment, and initiative, tempered with flexibility to deal with a rapidly changing healthcare environment and expanding technology
  • Have the ability to maintain concentration with attention to detail even in areas containing multiple levels of distraction
  • Must be self-motivated, well-organized, and possess excellent communication and analytical skills, as well as, strong facilitation and presentation/education skills
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Clinical Documentation Improvement Specialist Resume Examples & Samples

  • *Work Location: Long Island Jewish, New Hyde Park, NY***
  • RN experience OR Medical Graduate with CDI experience
  • 5+ years acute care hospital clinical experience
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Clinical Documentation Improvement Specialist Resume Examples & Samples

  • Be responsible for the day-to-day evaluation of documentation by the Medical Staff and healthcare team
  • Communicate with physicians, face-to-face or via clinical documentation inquiry forms, regarding missing, unclear or conflicting medical record documentation to clarify the information, obtain needed documentation, present opportunities, and educate for appropriate identification of severity of illness
  • Demonstrate an understanding of complications, co-morbidities, severity of illness, risk of mortality, case mix, secondary diagnosis, impact of procedures on the final DRG, and an ability to impart this knowledge to physicians and other members of the healthcare team
  • Participating at the organizational level in clinical documentation improvement initiatives
  • Preparing trended data for presentation one-on-one and small to medium groups of physicians
  • Provide daily clinical evaluation of the medical record including physician and clinical documentation, lab results, diagnostic information and treatment plans
  • Three years of previous clinical acute care nursing experience medical/surgical experience to include critical care in conjunction with an expanded knowledge of DRGs; OR completion of Health Records Administration program (RHIA) or Accredited Record Technician (RHIT) AND three years of experience with the Prospective Payment System and DRG selection; OR specific knowledge as a consultant in Medical Record coding and DRG assignment required
  • Prior CDI work experience preferred
  • Knowledge of computer technology, quality assurance activities, DRG, Quality Insights/Utilization review background is highly preferred
  • Ability to communicate with staff, physicians, healthcare providers, and other health care system personnel in a professional and diplomatic manner required
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Clinical Documentation Improvement Specialist Resume Examples & Samples

  • Evaluate documentation within a patient’s medical record to identify conflicting, incomplete, or nonspecific provider documentation impacting the appropriate assignment of the principal diagnosis, pertinent secondary diagnoses, and procedures for accurate DRG assignment, risk of mortality, and severity of illness
  • Facilitate consistent clinical documentation within the health record that reflects the level of patient care, continuity of patient care post discharge, coding and reporting of quality healthcare data
  • Adhere to AHIMA Ethical Standards for CDI Professionals, ACDIS Code of Ethics and AHIMA Standards of Ethical Coding
  • Query physicians regarding missing, unclear, or conflicting health record documentation by requesting and obtaining additional documentation within the health record when needed
  • Collaborate with case managers, nursing staff, and other ancillary staff regarding interaction with physicians on documentation and to resolve physician queries prior to patient discharge
  • Partner with the coding professionals to ensure accuracy of diagnostic and procedural data and completeness of supporting documentation to determine a working and final DRG, severity of illness, and/or risk of mortality
  • Act as an effective change agent and educator for physicians and key healthcare providers regarding clinical documentation improvement and the need for accurate and complete documentation in the health record
  • Assist leadership in the analysis and trending of statistical data for specified patient populations to identify opportunities for improvement
  • Assist with preparation and presentation of clinical documentation monitoring/trending reports for review with physicians and hospital leadership
  • Assist leadership in researching literature and industry trends to identify new methods development and overall documentation enhancement
  • Assist leadership in the development and reporting of performance measures to the medical staff and other departments and prepare physician specific data information
  • Contribute to a positive working environment and performs other duties as assigned or directed to enhance the overall efforts of the CDI Program and/or organization
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Clinical Documentation Improvement Specialist Resume Examples & Samples

  • Current RN License with 5+ years of acute care experience OR Medical School Graduate with Clinical Documentation Improvement experience
  • 2+ years of Clinical Documentation Improvement experience
  • If RN, BSN degree
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Clinical Documentation Improvement Specialist Resume Examples & Samples

  • *Work Location: Staten Island University Hospital***
  • Provides expert level review of inpatient clinical records; identifies gaps in clinical documentation that need clarification for accurate code assignment to ensure the documentation accurately reflects the severity of the condition and acuity of care provided
  • RN OR Medical Graduate with CDI experience
  • CCDS, CDIP, CPC or CCS certification
  • Clinical Documentation Improvement experience
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Clinical Documentation Improvement Specialist Resume Examples & Samples

  • Obtain appropriate clinical documentation through extensive interaction with physicians, nursing staff, other patient care givers
  • Collaborates with HIM 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
  • Facilitate appropriate and timely clinical documentation to ensure that level of services and acuity are accurately reflected in the medical record
  • Utilizes extensive knowledge of documentation requirements and guidelines in accordance with government and commercial payors to improve the overall quality and completeness of clinical documentation by performing reviews using the clinical documentation guidelines
  • Educate practice office physicians and staff on clinical documentation needs, changes to clinical documentation guidelines, coding and reimbursement issues
  • Conduct follow up review of clinical documentation to ensure proper clinical information is documented in the patient's record
  • Generate accurate and timely status reports for physicians & leadership
  • Associate's Degree in a relevant field preferred or combination of equivalent education and experience
  • Knowledge of clinical documentation guidelines and CDI program implementation experience preferred
  • Knowledge of disease process, medical terminology, ICD-9-CM and CPT codes
  • Knowledge of ICD-10 principles and further documentation specificity highly preferred
  • CCDS or CDIP in an active status with AHIMA or ACDIS is preferred
  • Excellent organizational, analytical, writing and interpersonal skills
  • Proficient computer skills – familiarity with Windows based software programs
  • Knowledge of Medicare Part A and Part B
  • Strong interpersonal and negotiation skills demonstrated by a positive attitude, pleasant, professional and cooperative demeanor with physicians, fellow employees & all customers
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Ambulatory Clinical Documentation Improvement Specialist Resume Examples & Samples

  • Provides education to providers on the appropriate code selection of Evaluation and Management (E/M), Current Procedural Terminology (CPT) and ICD-10 diagnosis codes
  • Performs pre-visit reviews of ACO patient accounts to flag potential diagnosis opportunities to support risk-adjustment and HCC coding
  • Achieves and maintains current knowledge and understanding of ICD-10-CM, E/M, CPT, and risk adjustment coding through participation in education and training, including comprehension of The 1995 and 1997 Documentation Guidelines for Evaluation and Management Services, ICD-10-CM Official Guidelines for Coding and Reporting, Coding Clinic and other regulatory education programs and updates
  • Demonstrates proficient knowledge of the Coding & Documentation Guidelines and standards of professional billing and risk adjustment coding and applies this knowledge to the evaluation of medical record documentation
  • Assists in the development of internal coding and documentation guidelines in accordance with risk adjustment and official coding guidelines
  • Provides education to the medical staff and healthcare providers regarding clinical documentation improvement and the need for accurate and complete documentation in the health record
  • Assists in development and training of the hospital CDS staff on ambulatory/outpatient CDI
  • Supports development of macros, templates, databases and other tools to support accurate documentation
  • Identifies trends and/or opportunities to improve clinical documentation
  • Presents opportunities and potential solutions to the providers and the ACO administration
  • Demonstrate the highest level of confidentiality and conducts self-according to AHIMA and AAPC Code of Ethics and ACDIS Code of Conduct
  • Performs assigned work safely, adhering to established departmental safety rules and practices; reports to supervisor, in a timely manner, any unsafe activities, conditions, hazards, or safety violations that may cause injury to oneself, other employees, patients and visitors