Clinical Documentation Specialist Resume Samples

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C Fahey

Camryn

Fahey

6994 Kohler Plaza

Detroit

+1 (555) 827 0196

6994 Kohler Plaza

Detroit

Phone

p +1 (555) 827 0196

Experience Experience

Chicago, IL

Clinical Documentation Specialist

Chicago, IL

Bins-Stokes

Chicago, IL

Clinical Documentation Specialist

Prepare documents for publishing process (including ensuring headings are correct, hyperlinking, updating and maintaining EndNote library)
Sitting, standing, and light lifting
Responsible for compliance with Organizational Integrity through raising questions and promptly reporting actual or potential wrongdoing
Serves as a clinical liaison between the clinical staff and coding staff by educating clinical staff of compliant documentation and accurate coding
Create and implement training and development for nursing staff, physicians and mid-level practitioners that addresses documentation issues & variances
Interacts with coding team to resolve documentation and coding issues and ensure proper DRG assignment
Performs on-site or electronic coding and clinical validation audits and interpretation of medical documentation to ensure capture of all relevant coding

Houston, TX

Risk Adjustment Clinical Documentation Specialist

Houston, TX

Lemke Group

Houston, TX

Risk Adjustment Clinical Documentation Specialist

Participate in data collection, analysis and reporting for program management and performance improvement
Provide routine formal and informal (just-in-time) Risk Adjustment and documentation improvement education to providers/staff
Manage and adjust to changing work volumes and priorities
Recognize opportunities for documentation improvement
Consistent and effective use of Compliant Documentation Management Program (CDMP) Risk Adjustment strategies
Timely follow up on all cases and resolution of those with clinical documentation clarifications
Formulate clinically credible documentation clarifications

present

Los Angeles, CA

Clinical Documentation Specialist Clinical Documentation Improvement East Orlando

Los Angeles, CA

Armstrong-Bernier

present

Los Angeles, CA

Clinical Documentation Specialist Clinical Documentation Improvement East Orlando

present

Assumes personal responsibility for professional growth, development and continuing education to maintain a high level of proficiency
Knowledge of regulatory environment
Reviews concurrent medical record for compliance including completeness and accuracy for severity of illness (SOI) and quality using the Compliant Documentation Management Program (CDMP) documentation strategies
Develop an active, collaborative interface and structure with Florida Hospital Medical Staff
Completes accurate and timely record review to ensure the integrity of documentation compliance. Completes accurate and concise input of data into CDMP Trak resulting in accurate metrics provided by the CDMP program. Understands and supports CDMP documentation strategies (upon completion of training) and continues to educate self and team members using educational tools, videos and provided WebEx’s
Strategically educates members of the patient-care team regarding documentation regulations and guidelines, including attending physicians, allied health practitioners, nursing, and care management. This includes quarterly compliance updates from Medicare
Completes well-timed follow-up case reviews on all concurrent cases with priority given for resolution of those with clinical documentation clarifications

Education Education

Bachelor’s Degree in Nursing

Ohio University

Bachelor’s Degree in Nursing

Skills Skills

Knowledge:Ability to demonstrate in-depth knowledge of concepts, practices and policies with the ability to use them in complex varied situations
Strong critical thinking skills and ability to integrate knowledge is necessary
Knowledge of personal computers and proficiency in the use of software applications such as Microsoft Word, PowerPoint and Excel
Having knowledge and experience, able to handle usual and seldom occurring job events
Strong attention to detail
Working knowledge of DRG methodology and knowledge of ICD-9 CM coding classification system
Strong broad-based clinical knowledge and understanding of pathology/physiology
Knowledge of quality and patient safety principles and processes
Ability to communicate effectively with physicians and other clinical professional staff
Basic computer skills/knowledge of Microsoft Windows

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Clinical Documentation Specialist Resume Examples & Samples

5+ years of experience with Adult Inpatient/Surgical care
RN / NP license
Knowledge of reimbursement cycle and DRGs

Clinical Documentation Specialist Resume Examples & Samples

2+ years of experience in Medical Records chart review
NYS RN license
Medicare Population experience
3M system experience/knowledge

Clinical Documentation Specialist Resume Examples & Samples

2+ years of experience as an RN or PA
Strong acute care experience
Clinical documentation specialist experience

Clinical Documentation Specialist Resume Examples & Samples

BSN/RN or PA
5+ years of acute care experience
DRG, MS-DRG and AP-DRG and CPT coding
Experience with Medicare/Medicaid guidelines
Clinical documentation experience or QM
Certification in CCDS, CDIP or CCS

Clinical Documentation Specialist Resume Examples & Samples

Minimum 2 years of pharmaceutical industry experience
Familiarity with various aspects of clinical trials and regulatory submissions
Current awareness of regulatory requirements for clinical trials (ICH/GCP)
Associates/Bachelor’s degree or equivalent preferred
Requires strong attention to detail, document organization skills, establishing priorities, scheduling and meeting deadlines
Ability to communicate effectively with external vendors, including issue escalation, and responding to inquiries and concerns

Clinical Documentation Specialist Resume Examples & Samples

Current New Jersey Registered Nurse license
Prior experience as a Clinical Document Specialist
Advanced organizational, analytical, writing and interpersonal skills
5+ years of clinical experience in a Critical Care setting, or strong Medical-Surgical background
Sound knowledge of the disease process and how it relates to Medicare, regulatory and DRG matters
Basic computer skills, knowledge of Windows software, and the capacity to support CDMP
CCN

Clinical Documentation Specialist Resume Examples & Samples

5+ years of Clinical experience with an Acute Care Inpatient background
Critical Care or strong Medical/Surgical experience
Experience with criteria-based chart review, such as Case Management, Utilization Management, Managed care, Quality Improvement
Solid critical thinking and analytical skills
CCDS / CCS certification
Previous Clinical Documentation experience
Knowledge of healthcare regulations, including Medicare reimbursement system, coding structure and documentation requirements

Clinical Documentation Specialist Resume Examples & Samples

5 years of Adult Acute Care experience in Medical-Surgical, Intensive Care, Emergency Department, or PACU
Care Management or Critical Care experience
Coding or billing experience

Clinical Documentation Specialist Resume Examples & Samples

5+ years of Acute Care Nursing or relevant Clinical experience
Graduate from an accredited program of Nursing with a Baccalaureate Degree or equivalent recent Clinical experience
Clinical Documentation Improvement certification
Previous experience with Chart Reviews and Medical Records

Clinical Documentation Specialist Resume Examples & Samples

3+ years of recent Clinical experience in an Acute Care setting
Educational Training in ICD-9-CM and CPT-4 coding practices
Current registration in the State of New Hampshire as a Registered Nurse or Certified Coding Specialist Graduate of an accredited School of Nursing
Knowledge of Medical Terminology, Anatomy and Physiology via courses or equivalent
Broad clinical knowledge base and understanding of DRG documentation requirements
Medical Coding experience

Senior Clinical Documentation Specialist Resume Examples & Samples

Strong broad based clinical knowledge and understanding of pathology/physiology of disease processes
Excellent interpersonal skills to build effective partnering relationships with physicians, nurses, and hospital staff
Working knowledge of Medicare reimbursement system and coding structures desired
Valid California Registered Nurse license or foreign medical graduate. CCS or ACDIS certification within 1 year of assuming position

Clinical Documentation Specialist Resume Examples & Samples

2+ years of recent Intensive Care Unit (ICU) Nursing experience
Certification in CDI
Case Manager experience

Clinical Documentation Specialist Hours Day Shift Resume Examples & Samples

Minimum of three years clinical experience in an acute care setting
Knowledge of care delivery documentation systems and related medical record documentation
Ability to work independently in a time oriented environment
Valid California Registered Nurse license and/or foreign medical graduate

Clinical Documentation Specialist Resume Examples & Samples

2+ years of related work experience
Previous experience with Program Planning / Development
5+ years of experience in an Acute Care setting

Clinical Documentation Specialist Resume Examples & Samples

Analyze clinical information to identify areas within the chart for potential gaps in physician documentation, formulate credible clinical documentation clarification to improve documentation of principal diagnosis and co-morbidities present upon admission
Identify strategies through data gathering and analysis of trends to establish recommendations for sustained work process changes that facilitate complete, accurate, clinical documentation to support correct coding and DRG assignment through extensive interaction with providers and HIM coding professionals
Queries physicians and other caregivers as necessary via approved written communication mechanisms to obtain accurate and complete documentation that supports the severity of patient illness, intensity of services and risk mortality
Performs monthly closed chart reviews and serves on the Utilization Review Committee
Serves as a resource for physicians to help link ICD-9-CM and/or ICD-10-CM/ PCS coding guidelines and medical terminology to improve accuracy of patient severity of illness, risk of mortality, and final code assignment
RN with relevant clinical experience
Graduate of an approved Health Information Technology/Management with credentials of RHIA, RHIT, RHIA/RHIT eligible, CCS, CCS-P, CCS/CCS-P eligible preferred
Demonstrated knowledge of ICD-9-CM, ICD-10-CM MSDRGs, documentation compliance standards and coding principles/guidelines preferred
2-3 years previous experience preferred
Must show ability to communicate effectively and diplomatically within a multi-functional team, including physicians, HIM coders, and other members of the allied health care team
Must possess strong organizational skills and attention to detail

Clinical Documentation Specialist Resume Examples & Samples

Minimum of 3 years current nursing experience (adult inpatient medical/surgical or critical care) is required OR
Minimum of 3 years current hospital inpatient coding experience
1+ year CDI program experience required
Strong clinical knowledge and demonstrated commitment to maintaining relevancy in clinical field
Extensive knowledge with MS-DRGs, APR-DRGs and the Inpatient Prospective Payment System (IPPS) required
Extensive knowledge with ICD-9-CM and ICD-10-CM Official Coding Guidelines required
General knowledge of what constitutes a complete and accurate record—i.e., complete and thorough clinical documentation beginning with the emergency room reflective of clinical presentation of patient; reason for admission that clearly establishes and meets medical necessity criteria; need for continued stay in the hospital including response to treatments, interventions, and outcomes; complete and accurate discharge summary
Effective ability and willingness to communicate benefits of complete and accurate documentation to physicians relating to their daily practice of medicine required
Ability to work with all physician specialties in clinical documentation improvement initiatives, effectively tailoring learning and education opportunities to each physician specialty on an “as you go” basis required
Analytic skills necessary to clinically assess medical records and communicate clinical detail required
Demonstrated excellence with written and verbal communication skills required
Experience in presentation development and presenting to groups preferred
Intermediate level computer skills in word processing and spreadsheet utilization required
General typing skills (35 WPM) required
Must be able to effectively communicate with and promote cooperation between attending physicians and residents either verbally or through written methodology to validate observations via the physician query process
Must be able to work closely with HIM and physician staff to assure documentation of discharge diagnosis and any co-existing co-morbidities are a complete reflection of the patient’s clinical status and care
Consistently meets established productivity targets for record review
Assists Manager with design and implementation of specific tools to support medical record physician documentation
Summarizes findings and presents to groups for purposes of education and improvement
Assists manager with development of both formal and informal education plan for physicians, nursing, and other clinical staff
Identifies strategies for sustained work process changes that facilitate complete, accurate clinical documentation
Facilitates multidisciplinary team in efforts for clinical documentation improvement

Clinical Documentation Specialist Resume Examples & Samples

Concurrent review of inpatient medical records throughout the patient’s hospitalization. Analyzes clinical status of patient, current treatment and past medical history and identifies potential gaps in physician documentation
Communicates with physicians or other providers to validate observations and appropriately prompts for documentation if necessary, either verbally or electronically
Demonstrates proficient knowledge of HIMS standards of coding and applies to ongoing evaluation of the medical record documentation
Analyzes clinical status of patient, current treatment and past medical history and identifies potential gaps in physician documentation
Identifies patients appropriate for the Hospital Quality Measures, and prompts RN and physician for clinical documentation according to the accepted standards
Educates physicians and other key healthcare providers regarding clinical documentation improvement and the need for accurate and complete documentation in the health record
Reviews and clarifies 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
Identifies trends and/or opportunities to improve clinical documentation. Presents opportunities and potential solutions to the clinical documentation initiative team
Attends coding/financial educational programs and regulatory educational programs and updates as necessary to maintain proficient knowledge base
Demonstrate the highest level of confidentiality and conducts self-according to AHIMA Code of Ethics and ACDIS Code of Conduct
Bachelor's required. Masters degree preferred
Registered RN licensed to practice in the State of DE required
Minimum of 3 years recent experience as a Registered Nurse in acute care, adult care setting, preferred
Med/Surg experience required, Critical Care experience preferred
Clinical Documentation, Case Management, Performance Improvement or Inpatient Coding experience highly desirable

Clinical Documentation Specialist PRN Resume Examples & Samples

Graduate of an associate's degree in nursing program or health information technology program
Working knowledge of inpatient admission criteria
Working knowledge of Medicare/reimbursement system and coding structures preferred

Clinical Documentation Specialist Resume Examples & Samples

Graduate of an approved Health Information Technology/Management program
Credentials of RHIA, RHIA eligible, RHIT, RHIT eligible, CCS, CCS-P and/or graduate from an accredited nursing program with RN license
Two years of experience in acute care setting
One year of inpatient coder experience preferred

Clinical Documentation Specialist Resume Examples & Samples

Work closely with faculty, answer their questions with regard to documentation and coding, understand and be the subject matter expert for their clinical and charge capture workflows, serve as a liaison to the Revenue Cycle Coding Unit
Assist faculty on coding for inpatient E&M, bedside procedures, SICU, and other locations
Prepare reports to provide feedback on provider and coding performance including state of documentation, charge capture, and reconciliation
Review and analyze clinical documentation to increase efficiency with physician reimbursement
Serve as resource for faculty on changes required for documentation of clinical services that may affect reimbursement
Serve as a resource on documentation requirements and ensure compliance with applicable laws and regulations
Perform analysis of patient care logs and other data to locate potential business opportunities or issues with respect to reimbursement or documentation of care
Assess opportunities for billing and provide necessary education on proper documentation for additional work performed
Perform audits of medical/surgical coding and give feedback to faculty
Initiate and compose letters to assist with clinical appeals to payers and Modifier 22 documentation for additional reimbursement
Meet regularly with Coding and Billing units to ensure constant communication between ACS and Revenue Cycle
This position will dually report to Acute Care Surgery and the Revenue Cycle Coding Unit. Acute Care Surgery will have day to day responsibility and the Coding Unit will provide training, perform reviews and quality assurance, and provide oversight over coding activities

Clinical Documentation Specialist Resume Examples & Samples

RHIT, RHIA, RN, or CCS required
Knowledge of care delivery documentation systems and related medical record documents
Detail knowledge and understanding and MSDRGs and OIG workplan as it relates to correct coding and MSDRG assignment
Excellent written and verbal communication skills, critical thinking skills and interpersonal skills to build effective relationships with physician, case management, nursing, coding staff and hospital staff

Clinical Documentation Specialist Resume Examples & Samples

Must possess at least five years of acute hospital nursing experience(e.g. medical/surgical unit, intensive care) Experience in Utilization Management/Case Management, Critical Care, patient outcomes/quality management and /or inpatient coding considered a plus
Prior experience in clinical documentation improvement, ICD coding and MS-DRG preferred
Prior experience in educating physicians/providers preferred
Minimum of one-year auditing experience strongly encouraged

Clinical Documentation Specialist Resume Examples & Samples

Registered Nurse (RN) or RHIA/RHIT with CCS
Bachelor's of Science in Nursing or Registered Nurse with 10 years acute care experience or RHIA/RHIT with 10 years inpatient coding experience
Advanced clinical expertise and extensive knowledge of complex disease processes with a broad clinical experience in an inpatient setting
Assertive personally traits to facilitate ongoing physician communication
Working knowledge of core measures

Clinical Documentation Specialist Resume Examples & Samples

Undergraduate degree required
Current California License (RN) or CCS – Certified Coding Specialist required
Completes continuing education requirements as determined by
Working knowledge of reimbursement systems and coding structures strongly preferred
Organization – proactively prioritizes initiatives, effectively manages resources and keen ability to multi-task
Managing conflict – dealing effectively with others in antagonistic situations; using appropriate interpersonal styles and methods to reduce tension or conflict between two or more people
Demonstrates leadership attributes
Adaptability – maintaining effectiveness when experiencing major changes in work tasks or the work environment; able to adapt to change in environment and/or circumstances with a positive outlook; and adjusting effectively to work within new work structures, processes, requirements, or cultures
Energy – consistently maintaining high levels of activity or productivity; sustaining long working hours when necessary; operates with vigor, effectiveness, and determination over extended periods of time
PC skills – demonstrates proficiency in software applications as required

Clinical Documentation Specialist Resume Examples & Samples

Assigns a working DRG for all selected admissions
Identifies and records principle diagnoses, secondary diagnoses, and procedures
Works in collaboration with the physician, nurse, patient care coordinator, and Medical Records coder, as appropriate

Clinical Documentation Specialist Resume Examples & Samples

Minimum of 5 years of adult acute care nursing experience in med/surg, critical care, emergency room, or PACU is preferred
Previous CDI experience desirable, but not required
Recent clinical experience preferred
Knowledge of ICD-10 desirable
Knowledge of Pathophysiology and Disease processes sufficient to pass the clinical pre-employment test at a rate of 70% or better is required
Knowledge of Federal regulatory rules regarding documentation and coding desirable
Ability to understand and communicate differences between Medicare Part A and Part B guidelines and how they impact DRG assignments (upon completion of training)

Clinical Documentation Specialist Resume Examples & Samples

Ability to communicate effectively w/ physicians
Thorough knowledge of clinical documentation requirements, coding, guidelines, and regulatory requirements related to coding
5 years of acute care hospital coding with a strong DRG background, or strong medical background with 3-5 years' acute clinical experience
Must be familiar with PC's and able to work with multiple technical systems simultaneously. Must be familiar with JCAHO, State and Medicare Standards
Ability to work in a multi-disciplinary environment
Must be detail oriented
Very strong communication skills, written and oral, for communication with Medical Staff and other healthcare professionals are a must for this role
Ability to perform well in a fast-paced, team environment and to manage time effectively. Reasoning Ability: Ability to define problems, collect data, establish facts and draw valid conclusions. Ability to interpret and deal with several abstract and concrete variables. Ability to effectively present information and respond to questions for groups of clients, physicians, and customers
Excel spreadsheet, Access database & PowerPoint experience a plus
Knowledge transfer, training experience or capabilities are a plus for this role
Prior report writing is a plus for this role

Clinical Documentation Specialist Resume Examples & Samples

Bachelors Degree in Nursing or other Health care related field or equivalent experience
CA licensure as RN preferred
Current knowledge of coding guidelines and required continuing education hours in nursing and/or coding
Minimum of 3 years clinical experience in an acute care setting. (For RHIA, RHIT, or CCS, minimum of recent 5 years inpatient coding experience in an acute care setting)
Broad acute clinical background with experience in more than one population preferred
Working knowledge of coding, APR and MS-DRG assignment process is preferred

Clinical Documentation Specialist, HIM DV Resume Examples & Samples

Utilizes the hospital designated clinical documentation system to identify opportunities for physician and hospital outcomes and identifies the most appropriate principal diagnosis and secondary diagnoses to accurately reflect the severity of illness
Maintains accurate data and skill in use of clinical documentation database and shares expertise with other members of the healthcare team. Trains other staff as directed
Responsible for the day-to-day evaluation of documentation by the Medical Staff and healthcare team in accordance with the hospital’s designated clinical documentation system
Assists in the development and reporting of performance measures to the medical staff and other departments and prepares physician specific data information

Clinical Documentation Specialist Resume Examples & Samples

Works collaboratively with medical, nursing and ancillary staffs to improve the quality of chart documentation that assures appropriate DRG classification to accurately reflect patient severity of illness and risk of mortality
Performs initial case reviews and appropriate number of follow-up reviews based on program standards
Uses clinical insight and judgment of clinical findings to assess clinical documentation for improvement opportunities
Follow-up with the physician responsible for care of the patient, via the query process, for clarification of clinical significance and appropriate documentation
Assigns the DRG based on coding guidelines/regulations issued by AHA (Coding Clinic), and CMS
Maintains professional competency by keeping abreast of new coding issues and guidelines. Attends classes and meetings as assigned. Reviews professional CDI and coding literature regularly
Interprets clinical information in medical record, evaluates medications, vital signs, surgical outcomes, etc. to identify potential documentation improvement opportunities
Identifies opportunities for physician education to improve medical record documentation for severity of illness
Contributes to and participates in educational efforts and activities
Participates in seminars, in-service/educational efforts and activities sponsored by professional associations at the local, state, and national levels. Fulfills continuing education requirements to maintain credential/license status
Communicates verbally, via email or writing with physician to obtain/clarify more specific documentation of the principal diagnoses, co- morbidities and complications. Requests clarification of existing documentation that most accurately reflects patient severity
Communicates cooperatively as needed s with coding specialists
Meets with the lead physician advisors, as needed
Communicates effectively with medical staff and Coding Quality Manager (as necessary) to acquire, interpret, and transmit accurate diagnostic and procedure information for billing
Keeps Program Director informed of potential and/or actual problems identified during the review process, concurrent progress and operation of program
Communicates tactfully and respectfully, always maintaining professional communication
Registered Nurse with a current license in the state of Massachusetts. Minimum of 6 years of acute medical/surgical care nursing is desired
Advanced computer functions and data entry required
Clinical Documentation Improvement experience required
Graduate of an approved school of nursing with current registration in MA. For newly licensed nurses a BSN is required
Ability to retrieve data from medical record required
Excellent communication and collaboration skills including writing, case presentation in a group setting
Ability to assess clinical severity of patients when reviewing charts
Accuracy in applying coding rules
Knowledge of coding rules and guidelines. Ability to recognize need for action and intervene quickly and diplomatically
Complex decision-making; makes good judgments; critical thinking skills
Strong organizational and collaborative skills
Flexible in work assignments
Self-directed and motivated to function both independently and on teams

Clinical Documentation Specialist Resume Examples & Samples

Effective interpersonal skills to interact effectively with all levels of hospital personnel
Effective written and verbal communications skills. Analytical skills. Proficient computer skills
Coding skills with experience in ICD-9-CM and working knowledge of the AHA Coding Clinic (some training provided)
A minimum of two years of experience in nursing or other clinical area, coding, or process improvement
Utilization review or Case Management experienced in an acute care facility

Clinical Documentation Specialist Resume Examples & Samples

Associates degree (or higher) in Nursing
Current MN RN licensure
At least 2 years Acute/Inpatient experience as an RN
Current RHIA or RHIT credentials
HIM degree with 5 years inpatient coding experience

Clinical Documentation Specialist Resume Examples & Samples

Performs inpatient medical record audits
Issues of compliance and facilitates CHS approved, best-practice physician documentation clarification requests
Tracks and reports CDIS activities
Develops and delivery of Physician, Coding and Clinical Documentation Improvement education through a variety of modalities
Provides Coders, senior leadership and facility personnel orientation to documentation improvement activities
Minimum of two years experience in clinical documentation improvement, ICD-9-CM and DRG’s
Minimum one year auditing experience
Prefer two years experience in providing physician and coder education in an acute care setting
Prefer previous experience working in a clinical documentation improvement department or as a consultant

Clinical Documentation Specialist PRN Resume Examples & Samples

O 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
Completion of RN/BSN/MSN Diploma program
Minimum of three (3) years recent acute clinical practice or related health care experience; ER, ICU, or Telemetry experience is strongly preferred

Lead Clinical Documentation Specialist Resume Examples & Samples

2-5 years CDI experience in an acute care facility required
Degree in Health Information Management, Medicine, or Nursing required. BS preferred
Current RN license required with Critical Care, OR, ER experience preferred; or RHIA/RHIT/CCS certification required; or MBBS required
CCDS, CDIP required

Clinical Documentation Specialist Resume Examples & Samples

Having knowledge and experience, able to handle usual and seldom occurring job events
Determine methods and procedures on new assignments and may provide guidance to nonexempt personnel
Bachelor's degree or equivalent and 9+ years related experience

Clinical Documentation Specialist Resume Examples & Samples

Must be familiar with PC's and able to work with multiple technical systems simultaneously
Must be familiar with JCAHO, State and Medicare Standards
*This job represents multiple job openings ***

Clinical Documentation Specialist Days Fountain Valley Resume Examples & Samples

Must possess a current RN license or an RHIA, RHIT, or CCS credential
Demonstrate knowledge of clinical or inpatient coding experience in an acute care setting required; 5 years experience strongly preferred
Familiarity with coding concepts and coding software desired
Strong broad-based clinical knowledge and understanding of pathology/physiology of disease processes
Excellent interpersonal skills to build effective partnering relationships with physicians, nurse staff, hospital management staff, and health information systems coding staff

Clinical Documentation Specialist Resume Examples & Samples

Registered Nurse with a current license in the state of Massachusetts
Minimum of 6 years of acute medical/surgical care nursing is desired
Graduate of an approved school of nursing with current registration in MA
For newly licensed nurses a BSN is required

Clinical Documentation Specialist Resume Examples & Samples

Superior clinical assessment skills required
Knowledge of care delivery documentation systems and related medical record documents required
Working knowledge of reimbursement systems and regulatory coding systems required (e.g. ICD-9-CM HCPCS, MS-DRGS)
Excellent observation skills, analytical thinking, problem solving, interpersonal, verbal and written communication skills required
Ability to make regular significant contacts with other personnel throughout and outside the medical center required in person, by telephone, or through correspondence
Good critical thinking skills required
Ability to assess, evaluate, teach, and be flexible with a working knowledge of all areas of adult medicine required
Associate’s Degree in Health Information Management, Nursing or other health care related field required
A minimum of five (5) years recent health information management, case management/utilization/quality review and/or other related clinical experience in an acute care facility required

Clinical Documentation Specialist Resume Examples & Samples

Must possess at least five years of acute hospital nursing experience (e.g. medical/surgical unit, intensive care). Experience in Utilization Management/Case Management, Critical Care, patient outcomes/quality management and/or inpatient coding considered a plus
ICU/Critical Care experience strongly desired
Previous experience working in a clinical documentation improvement department or as a consultant strongly encouraged
Candidate must possess excellent communication (verbal and written), interpersonal, collaboration and relationship-building skills
Strong critical thinking skills and ability to integrate knowledge is necessary
Must exhibit the ability to educate members of the healthcare team about clinical documentation
Individual must demonstrate data quality and integrity skills

Clinical Documentation Specialist Resume Examples & Samples

Conducts concurrent reviews of selected patient records to address legibility, clarity, completeness, consistency, and precision of clinical documentation
Demonstrates understanding of clinical documentation requirements to ensure that the severity of illness, risk of mortality, and services provided are accurately reflected in the record
Serves as a resource on appropriate clinical documentation
Communicates documentation discrepancies and coding definitions to the physicians both written and verbally as needed to clarify clinical documentation in accordance to query standards and/or policies
Conduct 1:1 educational sessions with physicians and other healthcare team members related to specific documentation requirements
Associate/Diploma Degree in Nursing and five - ten years acute care medical or surgical experience required. Bachelor of Science in Nursing preferred
Or a degree in Health Information Management with credentials of RHIA, RHIT, or CCS with extensive clinical knowledge and a minimum of 5 years inpatient coding experience will be considered in lieu of a RN
Licensure / Certification: Current license to practice as registered nurse in the State of Ohio
Registered Health Information Administrator (RHIA), Registered Health Information Technologist (RHIT), or Certified Coding Specialist (CCS) required
Experience: Minimum of 5 years acute care medical or surgical experience required; Utilization/Case Management, managed care, or Clinical Documentation and experience in ICD-10 coding conventions and DRG methodology preferred
Effective Communication Skills
Strong communication (verbal and written), interpersonal, organization and prioritization skills. Demonstrated ability to work effectively with physicians and handle multiple tasks and educational activities
Ability to analyze, interpret and assimilate information from various sources. Demonstrated knowledge in using clinical information systems and office automation
Possesses effective interpersonal skills, can work across departmental boundaries, facilitates problem resolution, and maintain a professional demeanor in difficult situations
Possesses enthusiasm and motivation to stimulate diverse individuals and groups

Clinical Documentation Specialist Resume Examples & Samples

Approximately five years of acute care nursing is required
Knowledge of data retrieval from medical records; QIO; perspective payment system (PPS); medical terminology; anatomy, physiology and disease pathology; and regulatory requirements set forth by QIO and CMS is required
Knowledge of report-writing; basic computer and data entry; mathematical calculations; Utilization Review/Management; and clinical skills is required
Ability to communicate effectively, both orally and in writing, accuracy, resourcefulness, interpersonal skills, critical thinking and decision-making skills, adaptability and supportive to change, detail-oriented and professionalism are required

Clinical Documentation Specialist Resume Examples & Samples

Following orientation period, meets established productivity targets for review of an average of 8-10 new inpatient medical records per day and 12 -15 re-reviews. If unable to perform reviews, seeks assistance from peers or supervisor
Formulates credible clinical documentation clarifications in 360’ format to improve clinical documentation of principal diagnosis, co-morbid conditions, present on admission status, and quality initiatives that support patient’s severity of illness, risk of mortality and patient safety indicators
Maintains an accuracy rate of 90% or greater in identifying correct concurrent initial and possible DRG when 2 or more diagnoses meet definition of PDX; reconciles correctly after coding to reflect highest severity and relative weight; ensures documented conditions, clarifications, and coded diagnoses are clinically valid and compliant; conducts follow up reviews for all cases, prioritizing according to LOS and DRG; utilizes process flow map in both concurrent and post discharge processes
Utilizes effective and appropriate communication with physicians of record, both verbally and through written methodology, to validate observations and suggest additional and/or more specific documentation to accurately reflect the patient’s condition. Manages electronic communication efficiently and effectively
Demonstrates knowledge of Coding Department standards of coding and applies to ongoing evaluation of medical record documentation and works closely with Coding staff to assure documentation of diagnosis (es) and any co-existing co-morbidities are a complete reflection of the patient's clinical status and care
Accurately inputs and analyzes data into the clinical documentation management program tracking tool and performs re-reviews on a timely basis to identify changes in a patient’s condition by completing follow up on or by writing new clarifications
Demonstrates competency in computer and network applications as necessary to perform role
Completes educational strategies to keep skills/knowledge current in documentation process and assists and supports with ongoing education for both formal and informal education of physician, nursing, and other clinical staff
Works collaboratively with healthcare team to facilitate documentation. Maintains good rapport and cooperative relationships. Approaches conflicts in a constructive manner. Helps identify problems, offers solutions, and participates in their resolution

Clinical Documentation Specialist Resume Examples & Samples

Concurrent review/Query process: Based on review of the existing medical record, determines principal diagnosis, qualifying secondary diagnoses, impacting procedures and assigns appropriate working DRG. Queries and educates providers to obtain greatest possible diagnostic specificity, and present on admission status, to accurately reflect the patient's condition. Adheres to industry standards pertaining to compliance
Consistently maintains quality and productivity standards: Meets daily review, query and query response targets. Participates in department performance improvement and employee engagement activities. Assist co-workers and management as workload requires by providing guidance to CDS staff regarding processes/procedures and coverage determinations
Minimum 5 years experience as a hospital inpatient nurse or hospital inpatient coder
Two years experience as a Clinical Documentation Improvement Specialist may offset the degree requirement

Clinical Documentation Specialist Resume Examples & Samples

Current California Registered Nurse ( RN ) License, Nurse Practitioner, Physician Assistant
Current Basic Life Support certification ( BLS ) for Healthcare Providers from the American Heart Association
5 years recent experience in an acute care setting
A minimum of one year of experience in the role of Clinical Documentation Specialist or one or more years of clinical skills in conjunction with prior coding experience
Must possess a diverse set of concurrent medical record review skills, clinical knowledge and knowledge of coding and reimbursement regulations under the Inpatient Prospective Payment System
Excellent observation skills, analytical thinking, problem solving skills
Good verbal and written communication
Bachelor's Degree in Nursing ( BSN )

Clinical Documentation Specialist Resume Examples & Samples

Current California Registered Nurse (RN) License, Nurse Practitioner, Physician Assistant
Current Basic Life Support certification (BLS) for Healthcare Providers from the American Heart Association
Bachelor's Degree in Nursing (BSN)

Clinical Documentation Specialist Resume Examples & Samples

California Licensed Registered Nurse, Nurse Practitioner, Physician Assistant, MD graduate/educated in foreign country, R.H.I.A., R.H.I.T., or C.C.S
Current Basic Life Support certification (BLS) for healthcare providers sponsored by American Heart Association. (NOTE: If employee/applicant has certification by the American Red Cross-CPR/AED for the Professional Rescuer, this will be accepted until card expiration date)
5 years recent clinical experience in a hospital setting
Occasional prolonged sitting
Occasional prolonged standing/walking
Occasionally pushes/pulls/move/lifts moderately heavy equipment (up to 50 lbs.)
Essential Technical/Motor Skills: Requires excellent observation skills, analytical thinking, problem solving, plus good verbal and written communication
5 years case management/ICU experience

Clinical Documentation Specialist Resume Examples & Samples

Completes initial and subsequent concurrent reviews of pediatric inpatient medical records in accordance with established timelines, in order to promote accurate code and DRG assignment and assessment of risk of mortality and severity of illness
Queries physicians regarding missing, unclear, or conflicting health record documentation by requesting and obtaining additional documentation in the health record when needed
Collaborates with case managers, nursing staff, and other ancillary staff regarding interaction with physicians on documentation issues and strives to resolve physician queries prior to patient discharge
Reviews and clarifies clinical issues in the health record with the coding professionals to support accurate DRG assignment, severity of illness, and/or risk of mortality
Educates physicians and key healthcare providers regarding clinical documentation improvement and the need for accurate and complete documentation in the health record
Participates in the analysis and trending of statistical data for specified patient populations to identify opportunities for improvement
Assists 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
Adheres to established departmental policies, procedures, and objectives
Engages in self-performance appraisal, identifying areas of strength as well as areas for professional development
Researches, selects and promotes adaptation of best practice findings to ensure quality patient care and optimal outcomes
Adapts behavior as needed to the specific patient population, including but not limited to: respect for privacy, method of introduction to the patient, adapting explanation of services or procedures to be performed, requesting permissions and communication style
BSN from NLNAC and/or CCNE accredited school of nursing or college strongly preferred. Previous experience as a clinical documentation specialist would be considered
BS in HIM from an AHIMA accredited HIM program plus at least 5 years of HIM inpatient coding experience (pediatric-focused coding preferred) may be considered

Clinical Documentation Specialist Resume Examples & Samples

Current RN licensure with five years recent clinical experience in a hospital setting; or a
CCDS certification through the Association of Clinical Documentation Improvement Specialists
Able to assess, evaluate, and teach
Proficiency in organization and planning
Proficiency in computer usage including database and spreadsheet analysis, presentation programs,
Demonstrates adaptability, flexibility, and self-motivation, and an ability to work independently
Knowledge of federal, state and private payer regulations preferred
Professional, team player, able to communicate well with others. Strong interpersonal skills and
Communicates with physicians, case managers, coders, and other healthcare team members to
Demonstrates competency for individual performance and development in the following areas

Clinical Documentation Specialist Case Management Resume Examples & Samples

Basic computer skills in word processing and spreadsheet utilization
Proficient in computer use (desktop and/or laptop)
Demonstrates basic knowledge regarding HIM coding standards
Analytic skills necessary to accurately assess patient medical records
Excellent interpersonal skills and ability to work on a team in order to influence physician documentation processes
Ability to be flexible and adjust to workload/assignment changes and interruptions

Clinical Documentation Specialist Resume Examples & Samples

Conducts initial and continued-stay concurrent reviews (every 2 days) on inpatient admissions and documents findings using Epic, denoting all key information utilized in tracking process
Identifies all procedures and secondary diagnoses for co-morbidities/ complications and documents appropriately using the 3M Encoder (CRS)
Identifies documentation issues such as quality, appropriateness, completeness, and reimbursement issues and communicates these issues to physicians and other caregivers so that immediate resolution can be made
Queries the medical staff and other providers as necessary via written/ verbal communication to obtain accurate and complete physician documentation which reflects the severity of the patient’s illness and risk of mortality, as well as documentation clarification for profiling, coding and equitable hospital reimbursement
Ensures the timeliness of all written and verbal queries from providers to ensure proper documentation is obtained and placed in the medical record before patient discharge
Educates physicians, clinicians, and other involved parties regarding the necessity of providing complete and clear documentation of the care provided throughout a patient’s stay to improve coding specificity and obtain equitable reimbursement
Applies federal and state documentation and coding (ICD 10) guidelines to ensure physician and hospital compliance. Maintains current knowledge of coding/documentation information including the AHA’s Coding Clinic publication, pharmacology, laboratory, disease processes, and new/ emerging technologies to ensure accuracy of code assignment and compliance
Identifies documentation trends and issues and reports these to HIM Director, CDI Manager, CDI Supervisor, as well as the inpatient coding management and staff
Interacts with coding team to resolve documentation and coding issues and ensure proper DRG assignment
Prepares and provides ongoing service-specific information and education to physicians and other care providers, related to provider documentation and its effects on coding, compliance, profiling and reimbursement
Monitors changes in laws, regulations and policies that impact documentation, reimbursement and compliance
Participates in educational programs and in-services in order to maintain and excel in clinical documentation requirements and coding skills
Portrays a professional manner in dress and all communication skills
Must have effective interpersonal skills to effectively interact, communicate and maintain good working relationships with all physicians and providers
Must be able to work with minimal supervision and assist others in completing the work of the team
Graduation from an accredited school of nursing, and two (2) years of professional nursing experience preferably in a medical or surgical area of an acute hospital setting
Graduation from an AHIMA accredited program as a Registered Health Information Administrator (RHIA) and at least three (3) years of recent inpatient coding experience
Graduation from an AHIMA accredited program as a Registered Health Information Technician (RHIT) and at least four (4) years of recent inpatient coding experience
An approved equivalent combination of education and experience
Maintain current licensure by the Minnesota Board of Nursing as a Registered Nurse(RN)
AND/ OR-
Registration as a Registered Health Information Administrator (RHIA) or
Experience in CDI activities

Clinical Documentation Specialist Resume Examples & Samples

Bachelor’s degree in Nursing
RHIA or RHIT credential
Clinical Documentation Improvement Specialist (CCDIS) certification
Experience with INTERQUAL or Milliman
Electronic Medical Record (EMR) experience preferred; Cerner strongly preferred
Three years of experience in acute care hospital or managed care case management or utilization review
Knowledge of federal, state and managed care rules and regulations including CMS and AHCCCS
Knowledge of ICD-9, ICD10, and MS-DRG, DRGs and medical necessity criteria
Current American Heart Association (AHA) BLS for Healthcare Provider certified
Excellent interpersonal skills and the ability to effectively communicate verbally and in writing with all levels of the organization and external contacts providing excellent customer service
Excellent organizational skills with the ability to prioritize, multitask and handle multiple priorities/tasks simultaneously in a fast paced environment
Ability to compose documents in a professional writing style
Ability to apply critical thinking, problem solving, and conflict management skills
Intermediate computer literacy and proficiency in Microsoft Windows
Intermediate proficiency in MS Office (Outlook, Word, Excel, PowerPoint)

Clinical Documentation Specialist Resume Examples & Samples

Responsible for improving the overall quality and completeness of clinical documentation by facilitating medications to clinical documentation through extensive interaction with physicians, nursing staff, other patient caregivers, and Health Information Management (HIM) coding staff to ensure that documentation reflects complete and accurate level of service rendered to patients
Conducts concurrent and retrospective clinically based reviews of inpatient medical records to ensure accurate representation of the severity of illness and also reimbursement compliance for acute care services provided
Ensures appropriate DRG classification is received for the level of service rendered to all patients with Diagnosis Related Group (DRG) payer
Serves as a clinical liaison between the clinical staff and coding staff by educating clinical staff of compliant documentation and accurate coding
Additional responsibilities will include conducting documentation reviews for inpatient admission criteria and formulating appeal letters for denial of services rendered

Clinical Documentation Specialist Resume Examples & Samples

Comprehensive clinical review of the Electronic Health Record focusing on physician/provider documentation
Coaching physicians, nurses and other clinicians on best practice documentation using effective communication skills and the established query process
Communication of issues related to documentation and coding to CDI Leadership
Collaboration with onsite CDI team and CDI leadership to achieve identified CDI system goals
Knowledge of CDI core concepts and processes and knowledge of Medicare Parts A and B, Coding Guidelines and quality initiatives

Clinical Documentation Specialist Resume Examples & Samples

Accurate and timely record review
Ability to access, manage and update patient medical records through Hospital Electronic Medical Record Information System
Formulate clinically credible queries
Effective and appropriate communication with physicians
Timely follow up on all cases especially those with queries
Participate in Task Force meetings
Manage multiple priorities
Knowledge of Medicare Part A
Familiar with Medicare Part B
Communicates with HIM staff and resolves discrepancies

Lead Clinical Documentation Specialist Resume Examples & Samples

Daily onsite management of the Clinical Documentation Specialists
Planning and execution of team huddles and other site based meetings
Coaching physicians, nurses and other clinicians on complete, compliant and accurate documentation
Assist CDS Manager in evaluation of care site CDSs
Collaboration with other disciplines to identify opportunities for improved workflow
Communication with HIM staff to resolve discrepancies
In depth knowledge of CDI core concepts and processes and knowledge of Medicare Parts A and B, Coding Guidelines and quality initiatives

Clinical Documentation Specialist Resume Examples & Samples

Current RN licensure with five years recent clinical experience in a hospital setting; or a RHIT/RHIA/CCS (including those grandfathered) with a minimum of two years ICD-9 Coding experience and significant clinical documentation knowledge and experience. (Incumbents in the role as of 1/1/2011 are grandfathered into the role)
CCDS certification through the Association of Clinical Documentation Improvement Specialists (ACDIS) with at least 1 year of Clinical Documentation Specialist experience preferred upon hire, OR certified within two years of hire date
Requires excellent observation skills, analytical thinking, problem solving, plus good verbal and written communication
Possesses a working knowledge of many areas of adult medicine
Able to assess, evaluate, and teach. Proficiency in organization and planning
Proficiency in computer usage including database and spreadsheet analysis, presentation programs, word processing and Internet searching
Ability and willingness to seek out and accept change
Professional, team player, able to communicate well with others. Strong interpersonal skills and positive attitude. Regular, significant contact with other personnel throughout and outside Memorial Hermann. Contact may be in person, by telephone, or through correspondence
Communicates with physicians, case managers, coders, and other healthcare team members to facilitate comprehensive medical record documentation to reflect clinical treatment, decisions, and diagnoses for inpatients
Gathers and analyzes information pertinent to documentation findings and outcomes
Develops physician education strategies to promote complete and accurate clinical documentation and correct negative trends
Identifies patterns, trends variances and opportunities to improve documentation review and process
Researches literature and stays abreast of CMS rules and regulations, incorporating changes to daily practice for overall documentation enhancement
Conferences with key physicians to review outcome information (including physician profile data if relevant) as it relates to documentation clarity, completeness, and correct DRG designation. Coaches physicians to improve their documentation so it more accurately reflects intensity of services and severity of illness. Documents conference and results
Attends various hospital service line meetings, reviewing outcome information, and educating physicians on service line specific improvement opportunities
Complies with HIPAA and Code of Conduct policies
Assists with special projects as needed. Performs other duties as assigned
Adheres to policies, procedures, and standards, within budgetary specifications, including time management, supply management, productivity, and accuracy of practice
Promotes individual professional growth and development by: meeting requirements for mandatory/continuing education and skills competency; supporting department-based goals which contribute to the success of the organization; and serving as preceptor, mentor, and resource to less experienced staff
Demonstrates competency for individual performance and development in the following areas: Customer Service, Job Skills, Resource Management, Teamwork, and Innovation. Director shall determine percentage weight distribution for each competency category

Clinical Documentation Specialist Resume Examples & Samples

>>>Knowledgeable in acute care nursing and accreditation requirements preferred. /> /> />
>>>>>>Current license in Virginia. /> /> /> /> /> />
>>>>>>>>>>Two years recent patient care experience. /> /> /> /> /> /> /> /> /> />
>>>>>>>>>>>>>>>Strong critical thinking skills and exceptional ability to integrate knowledge. /> /> /> /> /> /> /> /> /> /> /> /> /> /> />
>>>>>>>>>>>>>>>>>>>>>Excellent observation, communication and decision making skills. /> /> /> /> /> /> /> /> /> /> /> /> /> /> /> /> /> /> /> /> />
>>>>>>>>>>>>>>>>>>>>>>>>>>>>Be able to teach all members of the health care team of documentation guidelines. /> /> /> /> /> /> /> /> /> /> /> /> /> /> /> /> /> /> /> /> /> /> /> /> /> /> /> />
>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>Be able to communicate effectively with physicians. /> /> /> /> /> /> /> /> /> /> /> /> /> /> /> /> /> /> /> /> /> /> /> /> /> /> /> /> /> /> /> /> /> /> /> />

Mkt Manager Clinical Documentation Specialist Resume Examples & Samples

Conducts daily reviews of inpatient medical records to identify missing, vague, and/or incomplete diagnoses and procedures. Conducts timely follow-up reviews of clinical documentation to ensure that issues discussed and queries left in the medical record have been answered by the provider
Utilizes coding and clinical expertise to identify opportunities and ensure the accuracy and completeness of clinical documentation used for measuring and reporting physician and hospital outcomes
Queries physicians on specificity of procedures performed and diagnoses based on accepted coding guidelines, clinical expertise and LifePoint Hospitals query policy
Tracks and trends specific opportunities for CDI process improvement through the utilization of metrics reports
Conducts educational sessions with physicians and other health care team members on documentation requirements
Makes regular reports of progress toward goals associated with clinical documentation improvement opportunities and operational improvement plans
Assumes responsibilities for following compliance guidelines with federal, state, and local regulations within the department
Requires critical thinking skills, decisive judgment and the ability to work with minimal supervision. Must be able to work in stressful environment and take appropriate action

Clinical Documentation Specialist Resume Examples & Samples

Facilitates improvement in the overall quality, completeness and accuracy of medical record documentation
Reviews charts to assess the clinical status of patients, current treatment plan, and past medical history to identify potential gaps in clinical documentation related to outpatient encounters, with a particular focus on primary care visits
Performs on-site or electronic coding and clinical validation audits and interpretation of medical documentation to ensure capture of all relevant coding
A particular focus with be on Hierarchical Condition Categories (HCC) coding, which is used by CMS and other payers to determine illness complexity and estimate patient risk of future health care utilization
Leverages data provided by available information technology (such as billing data) to identify additional opportunities to improve the comprehensiveness and specificity of outpatient coding
Communicates and coordinates chart reviews with physician office staff and distributes correspondence (“CDQI alerts”) related to review
Analyzes returned CDQI alerts for accuracy and completeness
Reviews outpatient visit diagnoses and service levels prior to claim submission to ensure they accurately reflect the clinical status of patients and the type of care delivered
Proactively solicits clarification from physicians to ensure key aspects of care have been appropriately recorded in the patient’s chart
Participates in data acquisition, development of performance reports and communication of results to physicians, practice managers, and the CDQI leadership team
Interacts regularly with physicians, particularly primary care providers, in the outpatient setting, providing ongoing education regarding compliant documentation and accurate coding, and serves as clinical liaison to the coding department
Identifies training needs, prepares summary reports and conducts coaching as appropriate for clinicians and other staff to improve the quality of the documentation to accurately reflect members’ health status
Monitors coding changes by governmental agencies and other payers; educates practices on coding and compliance issues
Monitors activities to ensure that all clinical documentation is in compliance with
State and Federal payer regulations
Ability to communicate clearly and effectively with a wide variety of individuals at all levels of the organization
Strong time management skills
Must possess high degree of accuracy, efficiency and dependability
Excellent written and oral communication for representation of clear and concise results
Is familiar with APC coding and identifies front-end process improvement initiatives
Is familiar with HCC codes
Thorough knowledge of ICD-9-CM, ICD-10, CPT, and HCPCS
Strong communication and mentoring skills
Must have a minimum of 3 years coding experience with at least 1 year of HCC Risk Adjustment experience
Microsoft Word, PowerPoint and Excel- Intermediate
Internet applications- advanced
3M coder
Demonstrated ability to utilize a variety of electronic medical records systems
Level of Physical Activity Required: 1 Light 0 Moderate 0 Heavy

Clinical Documentation Specialist Resume Examples & Samples

Facilitates improvement in the overall quality, completeness and accuracy of medical record documentation through concurrent auditing and evaluation of the medical records
Facilitates modification of clinical documentation to ensure that appropriate reimbursment is received for the level of service rendered to all patients with a Diagnosis-Related Group (DRG) payer under Medicare
Analyzes clinical status of patient, current treatment plan and past medical history to identify potential gaps in clinical documentation
Assists in medical screening process, making referrals, interacting with case managers and clinical nurse specialists to ensure continuity of patient care as needed
Updates the DRG worksheet to monitor any changes in status, procedures/treatments, and confers with physicians to finalize diagnoses
Proactively solicits clarification from physicians to ensure points of clarification have been recorded in the patient's chart
Monitors activities to ensure that all clinical documentation is in compliance with State and Federal payer regulations
Educates nursing staff, patient caregivers and coding staff on compliant documentation opportunities, coding and reimbursement issues as well as provides clinical expertise to the coding staff
When scheduled, provides clinical documentation and biling compliance education with support Federal and State rules and regulations
4 years as CCA (Clinical Coding Analyst), CCS (Clinical Coding Specialist) or CCDS (CertifiedClinical Documentation Specialist)
Knowledge of ICD-9 and current Medicare and Medicaid regulations regarding clinical documentation and billing compliance for Part A and B services
Internet applications- Advanced 3M encoder
Demonstrated and interpersonal skills to work effectively with a variety of individuals and groups both internally and externally
Ability to use basic data entry and retrieval systems
Ability to follow up on issues and communicate effectively to appropriate personnel
Willingness to seek opportunities for professional growth and to enhance current knowledge of billing compliance
Excellent problem solving, organizational and analytical skills
Demonstrated knowledge of ICD-9 codes, DRG and CPT coding

Clinical Documentation Specialist Resume Examples & Samples

Proficient in all (3) grouper systems, facilitates improvement in the overall quality, completeness and accuracy of medical record documentation through concurrent auditing and evaluation of the medical records
Facilitates modification of clinical documentation to ensure that appropriate reimbursement is received for the level of service rendered to all patients with a Diagnosis-Related Group (DRG) payer under Medicare
Proactively solicits clarification from physicians to ensure points of clarification have been recorded in the patient’s chart
Reviews clinical issues with coding staff to assign a working DRG
Educates nursing staff, patient caregivers and coding staff on compliant documentation opportunities, coding and reimbursement issues as well as provides clinical expertise to the coding staff. Takes a lead role in education and mentoring less senior staff

Contingent Clinical Documentation Specialist Resume Examples & Samples

1 Ensures accuracy and completeness of all clinical information/documentation used for measuring and reporting physician and hospital outcomes
2 Educates all internal customers on compliant documentation opportunities , coding and reimbursement issues, as well as performance improvement methodologies
3 Conducts follow up reviews of clinical documentation to ensure points of clarification have been recorded in the patients medical record (Queries)
4 Participates in the monthly collection of documentation metrics/data that is downloaded and sent to JA Thomas and Trinity Home Office as it relates to Program outcomes
5 Develops and fosters effective working relationships with Physicians, AHP's, Residents, Case Managers, Nursing, Coders and other members of the Health Care Team
6 Facilitates explanations to clinical documentation to ensure that appropriate reimbursement is received for the level of service rendered to all patients with a DRG based payor
7 Identifies DRG payor and documentation opportunities and works to provide clinical information and education to the Health Care Team to improve overall documentation outcomes
8 Participates and actively manages their individual caseloads in the CDMP Trak Program by transferring discharged patients into Trak when final DRG disposition has been completed by Coding
9 Participates in Hospital wide committees and projects specific to Clinical Documentation improvement opportunities including CDMP Task Force and Steering Committee
10 Conducts timely follow up on Retrospective Queries for documentation clarification
11 To perform this job successfully, an individual must be able to perform the competencies/essential functions satisfactorily with or without reasonable accommodation

Clinical Documentation Specialist Resume Examples & Samples

4 year Bachelor's Degree: Nursing is required; Master's Degree is preferred
Registered Nurse Certified is required; RHIA, RHIT is strongly preferred
4-6 years of Clinical Nursing or Health Information Management (HIM) experience is required; 6-9 years is preferred
3 years of Clinical Documentation experience is preferred; remote work option possible depending on prior clinical documentation experience
Strong verbal communication and basic computer skills

Clinical Documentation Specialist Resume Examples & Samples

Reviews inpatient medical records prospectively to ensure that the care of the patient is recorded in language that payers can interpret and which accurately and completely depicts acuity of the patient and resources expended. Reviews surgical procedures to ensure documentation is accurate for ICD/10-PCS code assignments
Operationalizes and institutionalizes documentation practice that accurately and completely depicts acuity of the patient and resources expended. All methods adhere to coding clinic and hospital compliance guidelines
Create and implement training and development for nursing staff, physicians and mid-level practitioners that addresses documentation issues & variances
Develops, maintains and improves upon effective and accurate IS systems for managing, tracking, and analyzing data (including working with Fiscal IS Decision Support)
Tracks DRG assignments against national benchmarks to identify documentation variances. Identifies potential solutions, whether general education or targeted interventions, where inconsistencies can be improved upon and rectified
Associate's degree required. Bachelor's degree preferred
License Registered Nurse required., and Certificate 1 Certified Professional Coder preferred
3-5 years related work experience required in a clinical nursing practice, which includes medical, surgical and/or ICU background
BS in Nursing with 5-8 years of acute care clinical experience
Experience/Education of DRG Reimbursement and ICD-9/ICD-10 Coding. CCDS/CCS or coding experience
Advanced skills with Microsoft applications which may include Outlook, Word, Excel, PowerPoint or Access and other web-based applications preferred

Risk Adjustment Clinical Documentation Specialist Resume Examples & Samples

Review medical record(s) for completeness, accuracy, consistency and clinical evidence for severity of illness (appropriate capture of true disease burden and quality using official Risk Adjustment and relevant official documentation/coding guidelines
Accurate, comprehensive and timely medical record review
Consistent and effective use of Compliant Documentation Management Program (CDMP) Risk Adjustment strategies
Formulate clinically credible documentation clarifications
Request documentation clarifications as appropriate for severity of illness
Effective and appropriate communication with Providers
Timely follow up on all cases and resolution of those with clinical documentation clarifications
Provide routine formal and informal (just-in-time) Risk Adjustment and documentation improvement education to providers/staff
Participate in Risk Adjustment steering committee meetings
Manage and adjust to changing work volumes and priorities
Communicate with HIM and/or billing staff and resolve discrepancies
Document activity and outcomes accurately, consistently, and in timely manner
Participate in data collection, analysis and reporting for program management and performance improvement

Clinical Documentation Specialist Resume Examples & Samples

Completes review of medical record for each assigned patient as required and follows up with appropriate healthcare team members to ensure accurate and complete documentation is in the medical record
Demonstrates an understanding of complications, co-morbidities, severity of illness, risk of mortality, case mix, secondary diagnosis, impact of procedures on DRG, and is able to impart this knowledge to physicians and other members of the healthcare team
Processes discharges by updating the DRG worksheet to reflect any change in status, procedures/treatments, and confers with physician to finalize diagnoses
Coordinates education to all internal customers related to compliance, coding, and clinical documentation issues and acts as a consultant to coders when additional information or documentation is needed to assign the correct DRG
Reviews the medical record to confirm the assigned principal diagnosis and assign any additional significant secondary diagnoses and procedures that may impact the DRG assignment. Prompts the physician (verbal and/or written) when appropriate. Assigns the most accurate final DRG by the time of discharge to minimize post-discharge queries
Identifies patterns, trends variances, identifies opportunities, and interprets monthly tracking reports of findings and identifies opportunities for improvement
Maintains liaison with the Case Management and Quality departments in order to evaluate and monitor CQI requirements and develop education and communication plans to improve outcomes

Clinical Documentation Specialist Resume Examples & Samples

RN,BSN preferred
Associates Degree from an accredited School of Nursing or Licensed Practical Nurse or RHIT/RHIA Certified
Licensed as a Registered Nurse in the state of GA or Registered Health Information Administrator (RHIA)
Five (5) years recent clinical experience in a hospital setting, or four (4) years recent clinical experience and two years ICD-9 Coding experience (optional)
Utilization Review, Care Management or coding experience preferred
Professional, team player, able to communicate well with others. Strong interpersonal skills, pleasing personality, positive. Regular significant contacts with other personnel throughout and outside the Hospital. Contacts may be in person, by telephone, or through correspondence
Flexible with a working knowledge of all areas of adult medicine
Sitting, standing, and light lifting
Good critical thinking skills, able to assess, evaluate, and teach
Flexible with strong knowledge of all areas of adult medicine
Uses sight and sensory
Works 8 hours a day, Monday thru Friday, start and stop time flexible depending on assignments
Serve the population of physicians, patients, family members, and employee

Clinical Documentation Specialist Resume Examples & Samples

Bachelor’s degree in Nursing or equivalent is required
Current RN License in the State of Maryland, or eligible to practice due to Compact state agreements outlined through the MD Board of Nursing, is required
Five (5) years of experience as a Registered Nurse required
Experience in Chart Review, Case Management, Utilization Review, Medical Record or coding experience is preferred
Strong knowledge of all legal regulations is mandatory to ensure all patient documents and records are maintained in accordance with those guidelines
Working knowledge of The Joint Commission; ISDH and CMS regulations as they relate to medical documentation and health information management
Clinical chart review and abstraction experience strongly preferred
Basic computer skills in word processing and spreadsheet utilization are required. Database data entry and/or management experience preferred
Highly effective verbal and written skills are required to work successfully with a diverse group of staff at various levels within the organization
Statistical knowledge preferred
Demonstrated ability to prioritize work and work independently
Demonstrated analytical skills necessary to clinically assess medical records
Demonstrated ability to work collaboratively with other team members
Ability to demonstrate knowledge and skills necessary to provide care appropriate to the patient population(s) served. Ability to demonstrate knowledge of the principles of growth and development over the life span and ability to assess data reflective of the patient's requirements relative to his or her population-specific and age specific needs
Reports adverse events and near misses to appropriate management authority
Identifies possible risks in processes, procedures, devices and communicates the same to those in charge

Clinical Documentation Specialist Resume Examples & Samples

Identifies trends and opportunities for improvement in clinical documentation in relation to federal, state or private third party payers
Meets program quality and productivity guidelines and standards
Collaborates with coding professionals to fully support the needs of clinical code assignment,
RN and/or RHIA
3-4 years experience
Successfully manages multiple priorities required
Successful completion of specialized training in organizational,analytical, writing, and interpersonal skills required
Specialized training in advanced computer skills with proficiency in Microsoft Word, Excel, Power Point, and Outlook e-mail required
Additional training in Access database management, Medicare Part A and B programs, DRG assignment, and knowledge of MCC/CC preferred

Clinical Documentation Specialist Resume Examples & Samples

BA/BS degree required
1-2 yrs. of Clinical Trial experience
Maintain clinical trial files in electronic Trial Master File
Perform QC checks on documents supporting global clinical trials to ensure complete
Prepare documents for publishing process (including ensuring headings are correct, hyperlinking, updating and maintaining EndNote library)
Draft documents for IRB submissions, including manuals of operations, schema, ICFs, protocol summaries
Prepares and ensure documentation is complete for Sponsor audits
Update documents for distribution in clinical trial management system including creation of source documents for Investigator Site Files

Clinical Documentation Specialist Resume Examples & Samples

Interacts with ancillary departments to obtain missing information needed to properly support billing accounts based on documentation in the medical record
Attends daily case management meetings
Partners with HIM coding professionals to ensure accuracy of diagnosis and procedural data and completeness of supporting documentation to ensure documentation of discharge diagnoses and any co-morbidities
Educates providers one-on-one in understanding the clinical documentation requirements for diagnosis capture both formal and informal. This includes nursing and other clinical staff regarding clinical documentation improvement and the need for accurate and completed documentation in the health record
Identifies clinical documentation issues and works with ancillary departments to resolve issues and notify appropriate leadership
Maintains clinical database updated and current. Produces reports as requested and produces monthly summary reports of cases reviewed. Reviews results for patterns, specific clinical issues and overall issues for noncompliance or possible educational needs
Performs concurrent record reviews on all selected admissions and documents findings
Serves as a team member and assists in recovery audit process reviews
Serves as a resource for physicians to help link ICD-9 and ICD-10 CM coding guidelines and medical terminology to improve accuracy of documenting patient severity of illness, risk of mortality and final code assignment
Monitors and evaluates effectiveness of concurrent chart review and query outcomes at designated intervals
Adheres to all compliance guidelines and maintains strictest confidentiality
Supportive of the compliance program set forth by IASIS and demonstrated by
Upholding the Standards of Conduct and Corporate Compliance
Adheres to and helps to enforce all compliance policies relevant to his/her area
Assures timely compliance education as requested by the Regional Compliance & Safety Officer and/or through corporate initiatives
Consistently supports and communicates the Mission, Vision and Values of SJMC
Follows the SJMC guidelines related to the Health Insurance Act of 1996 (HIPPA) designed to prevent and detect unauthorized disclosure of protected health information (PHI)
Promotes a culture of safety for patients and employees through proper identification, proper reporting, documentation and prevention of medical errors in a non punitive environment
Maintains and uses proficiency in communication skills, both written and verbal
Five years of experience in an acute care setting
Prior experience in clinical documentation improvement programs preferred
Able to establish good customer relationships with trust and respect
Computer skills: navigation and edit resolution through various Web based systems; Proficient use of Microsoft office, specifically excel, Word, Outlook
Self directed, motivated and a positive attitude
Must exhibit excellent organizational skills
Clinical documentation knowledge as it relates to DRGs, POA, MCCs and CCs preferred
Understanding of the coding classification systems, ICD-9, ICD-10, CPT, HCPCS
Clinical knowledge to read and analyze a patient’s health record
Clinical understanding of pharmacology, pathophysiology, labs, radiology and disease processes

Lead Clinical Documentation Specialist Resume Examples & Samples

Lead and coordinate the day-to-day activities of the Clinical Documentation Integrity (CDI) operations at the care sites. Oversee individual CDS workload/assignments. Monitor reporting time/timeliness. Serve as a resource for internal customers and Clinical Documentation Integrity Specialists (CDSs)
Assist in implementing new SCL Health CDI policies and procedures related to CDI and coding guidelines. Accountable for dissemination of all facility-specific and CDI-specific information to CDSs and adherence of CDSs to requirements
Assist with planning and leading of Care Site huddles
Assist with planning and leading CDS peer review activities
Serve as 2nd level reviewer for all cases with unanswered queries being considered for escalation to Physician Champion/CMO, and aid in the escalation as appropriate for the case
Act as a CDI liaison for other Care Site disciplines to facilitate coordination and collaboration as needed to achieve goals (for example, Case Management, UR, Nursing, Wound Care, dieticians, etc.)
Assist with quality assurance activities for the Care Site and CDI department as directed by CDI Leadership. Audit work of CDSs for accuracy, productivity and quality standards. Proactively identify issues or trends, and propose solutions
Communicate issues or concerns with site CDI operations to system CDI Leadership
Arrange and deliver education for providers and care givers based on identified opportunities. Educational content is done through collaboration with System CDI Educator/Manager and Care Site CDI team
Serve as a mentor and subject matter expert to new CDS associates
Assist CDS Manager in evaluation of care site CDSs – participate in performance improvement/action plan activities as needed to assure all CDSs are meeting or exceeding performance expectations
Work 50% of time as Clinical Documentation Specialist reviewing charts and work with providers for improved documentation unless approved otherwise by CDI Manager or Director
Participate in continuing education programs to maintain an understanding of anatomy, physiology, medical terminology, disease processes and surgical techniques to support the effective application of coding guidelines to inpatient diagnoses and procedures
Enhance professional growth and development through participation in professional organizations, coding roundtables, literature reviews, and relevant workshops
Promote the mission, vision, and values of SCL Health, and abide by service behavior standards
Ability to deal with conflicting interests and to resolve situations effectively
Ability to effectively communicate, both orally and in written form, with people at all levels of the organization, including Senior Leadership
Possess strong clinical and critical thinking skills
Proficient computer skills necessary in order to perform the tasks required, including intermediate knowledge of databases and spreadsheet applications required (Excel)
3M CDIS preferred or ability to learn

Clinical Documentation Specialist International Md-days Resume Examples & Samples

Facilitates appropriate clinical documentation to ensure that the overall quality, level of services, severity of illness, and acuity of care are accurately reflected in a complete medical record, yielding the appropriate reimbursement for the level of services rendered and resources consumed
Provides updated data and information to providers regarding clinical documentation physician education opportunities, coding and documentation issues, and performance improvement opportunities. In collaboration with the Provider Specialists, conducts on-site provider education events/opportunities and align with the CDI program to review targeted opportunities for provider training opportunities
Maintain dynamic communication with coders to identify root cause of CDI-Coder final DRG mismatch and seek to resolve incongruence with appropriately assigned final DRG
Ability to facilitate understanding, compliance, and completeness in documentation
Work performance goals embrace achieving best practice metrics for compliance and workflows that include multidisciplinary team processes for CDI and Coding staff
Advanced clinical expertise with an in depth understanding of anatomy and physiology
Extensive knowledge of complex disease processes with a broad clinical experience in an inpatient setting
Demonstrates clinical knowledge skills/abilities for the patient population served
Ability to work effectively under pressure due to changing priorities, interruptions, high and low census, and payer population work list changes
Education: Bachelor’s Science Degree in a healthcare related field
Experience: 5 years working in an acute inpatient hospital setting as a Clinical Documentation Specialist. ICD-10 experience
License/Certification: Certified Clinical Documentation Specialists (CCDS) or Clinical Documentation Improvement Professional (CDIP) credentials

Clinical Documentation Specialist Resume Examples & Samples

Performs admission and continued stay reviews, considering clinical issues with coding staff and ministry specific CDI team to assign a working/CDS DRG, based on a proficient knowledge of documentation requirements and guidelines in accordance with Coding Clinics and SJHS compliance
Utilize the ICD-10 Compass tool and other resources to validate documentation concepts necessary in ICD-9/10 documentation for the CDI team, clinical teams, and providers
Supports providers in maintaining an updated problem list in Meditech
Supports the development of new workflows that help imbed documentation concepts into the provider’s daily work (i.e. problem list, orders, 3rd Party Application such as ePREOP and Iodine) and assists with the education of these tools and workflows to maximize compliance
Be a positive contributor in how documentation will affect the Hospital Value-Based Purchasing (VBP) results, how patients are included in the Potentially Preventable Readmissions (PPR), and to identify those conditions that may be Hospital Acquired Conditions (HAC) vs. Present on Admission (POA) conditions, and penalties will be associated with lack of proper documentation
Analyze provider data in concurrence with the Provider Specialist, looking for individual, group, and peer outlier trends that could benefit from additional education. Convey support and education as needed to providers focused on improving processes and the quality of their documentation on a case-by-case basis to accurately reflect patient care in the medical record
Provider feedback may be distributed through face-to-face education, attending practice group meetings, medical directors and formal medical staff committees regarding the status and trends of the integrity of their documentation
Excellent verbal and written communication skills and an expert at interpersonal communication (verbal, non-verbal, and listening skills)
Knowledge of coding classifications systems such as, but not limited to, ICD-9-CM, MS-DRG, APR-DRGs, and HCCs strongly preferred
Knowledge of ICD-10 and its impact on providers and CDI staff practices
Ability to collect, analyze, and interpret data (CDI) for physician endorsement of program initiatives
Knowledge of the healthcare revenue cycle
Knowledge of physical and psychological characteristics of illness and medical terminology
Knowledge of age related developmental stages and needs
Proficiency in influencing medical staff changes in documentation
Proficiency in negotiation of complex systems to affect change
Ability to work collaboratively on a team
Ability to work independently and make decisions
Education: RN with an Associate’s Degree or a Bachelor’s Science Degree in a healthcare related field with 5+ years of CDI experience
Experience: 3 - 5 years in an acute inpatient hospital setting. Strong clinical background
If RN or other health related license present on hire or obtained in course of employment, must maintain that license
Education: Bachelor of Science degree in Nursing
License/Certification: RN License, Certified Clinical Documentation Specialists (CCDS) or Clinical Documentation Improvement Professional (CDIP) credentials

Clinical Documentation Specialist Resume Examples & Samples

Understanding of organizational policies and procedures
Working knowledge of quality improvement theory and practice
Demonstrates adaptability and self-motivation by staying abreast of CMS rules, and regulations and incorporating those changes into daily practice
Team building skills with the ability to function independently and interdependently as a member of a network team
Demonstrates the ability to be flexible in work schedules and coverage at any site
Knowledge of federal, state and private payer regulations

Clinical Documentation Specialist Resume Examples & Samples

Review inpatient medical records for identified payor populations and analyze clinical information to identify areas within the medical record for potential gaps in physician documentation
Formulate credible clinical documentation clarifications to improve clinical documentation of principal diagnosis, co-morbidities, present on admission (POA) and/or quality measures
Facilitate modifications to clinical documentation through extensive interaction with physicians, nurses and ancillary staff based on knowledge of DRG assignment, documentation strategies, and clinical documentation requirements
Work collaboratively with coding professionals to assure documentation of discharge diagnoses and comorbidities are a complete reflection of the patient's clinical status and care
Educates all internal customers on compliant documentation responsibilities, coding and reimbursement issues, as well as performance improvement methodologies

Clinical Documentation Specialist Resume Examples & Samples

Facilitates modifications to clinical documentation to ensure that appropriate reimbursement is received for the level of service rendered to all patients with a DRG based payor
Improves the overall quality and completeness of clinical documentation by performing admission/continued stay reviews using Compliant Documentation Program Management (CDMP®)guidelines and software
Processes discharges by updating the DRG Worksheet to reflect any changes in status, procedures/treatments, and conferring physician to finalize diagnoses
Educates all internal customers on compliant documentation opportunities, coding and reimbursement issues, as well as performance improvement methodologies
Participates in performance improvement activities aimed at improving compliant documentation, medical record coding, clinical outcomes, collaborative practice, financial outcomes, and other pertinent performance indicators as defined by the organization
Adheres to the policies, procedures, rules and regulations of the hospital as well as regulatory bodies and all Federal and State laws and regulations

Clinical Documentation Specialist Resume Examples & Samples

Provides nursing care, ensures an environment of patient safety, promotes evidence-based practice and quality initiatives and exhibits professionalism in nursing practice within the model of the ANCC Magnet Recognition Program®
Collaborates with the multi-disciplinary team, including physicians, patient care services, case management, coding specialists and other healthcare disciplines regarding clinical documentation issues
Utilizes computer systems effectively and maintains record of reviews completed, queries completed and outcome of physician response
Responsible for compliance with Organizational Integrity through raising questions and promptly reporting actual or potential wrongdoing
Education: Associate/Diploma Degree in Nursing and five - ten years acute care medical or surgical experience required. Bachelor of Science in Nursing preferred. A degree in Health Information Management with credentials of RHIA, RHIT, or CCS with extensive clinical knowledge and a minimum of 5 years inpatient coding experience will be considered in lieu of an RN
Licensure/Certification: Current license to practice as registered nurse in the State of Ohio. Registered Health Information Administrator (RHIA), Registered Health Information Technologist (RHIT), or Certified Coding Specialist (CCS) will be considered in lieu of a RN
Strong communication (verbal and written), interpersonal, organization and prioritization skills; Demonstrated ability to work effectively with physicians and handle multiple tasks and educational activities
Ability to analyze, interpret and assimilate information from various sources
Demonstrated knowledge in using clinical information systems and office automation

Clinical Documentation Specialist Resume Examples & Samples

Address abnormal ancillary test findings when they occur and query physicians regarding the impact on patient care and DRG assignment
Gathers and analyzes clinical and financial information from a variety of internal and external sources, relating to patient safety, utilization of resources, physician practice patterns, system problems, and other quality functions. Identifies trends, variances, deficiencies, and problems utilizing aggregated data and information
Initiate physician interaction when ambiguous or conflicting information is in the medical record, providing guidance to Case Management, physicians, and hospital staff regarding documentation for correct coding and compliance necessary for increased CMI, decreased LOS, and optimal resource utilization
Obtains appropriate clinical documentation through extensive interaction with physicians, nursing staff, medical staff, ancillary staff, and HIM coding staff utilizing Joint Commission, Federal and State regulations
Perform monthly retrospective reviews for DRG verification with focus upon questionable DRGs focused OIG work plan and CMS, also performing any organizational trends or patterns noted
Utilizes ICD-9-CM hospital coding policies and procedures, Federal and State coding reimbursement guidelines, and application of the Coding Clinic Guidelines to assign working DRG, reviewing patient records throughout hospitalization that have been identified as focus DRG by regulatory agencies or the facility to ensure the codes are reported at the highest specificity
Verifies appropriateness of assigned admission status communicating all discrepancies to Admitting Services for immediate correction
Ability to communicate effectively, using excellent verbal and written skills, as well as apply critical thinking, creative problem-solving, and conflict management skills
Ability to perform accurate clinical chart abstractions and initiate documentation queries based on clinical signs, symptoms, diagnostic findings and treatment
Ability to understand and correlate the significance of clinical documentation to compliance with Joint Commission guidelines, core measures, National Patient Safety Goals (NPSG), and AHRQ patient safety indicator measures
Ability to work productively and cooperatively with individuals at all levels of the organization, including physicians, HIM/coders, and quality managers/analysts
Knowledge of coding clinic guidelines, ICD-9-CM official guidelines for coding and reporting, AHIMA standards of ethical coding, and AHIMA query guidelines
Knowledge of MS-DRG and APR-DRG systems, which includes CC/MCC impact, severity of illness, risk of mortality, role of principal and secondary diagnosis, and impact of procedures on DRG
Knowledge of personal computers and proficiency in the use of software applications such as Microsoft Word, PowerPoint and Excel
Knowledge of quality and patient safety principles and processes

Clinical Documentation Specialist Resume Examples & Samples

Working knowledge of coding structures
Ability to work independently in time oriented environment
Strong communication skills – both written and verbal
Good interpersonal skills, with ability to identify and effectively resolve issues

Clinical Documentation Specialist Resume Examples & Samples

5 years of medical-surgical or CCU experience
CCU experience
AHIMA
Previous CDI experience
Previous experience in medical record chart review
Ability to communicate effectively with physicians and other clinical professional staff
Demonstrated proficiency with computer systems and database software
CCS or CCDS experience
Working knowledge of DRG methodology and knowledge of ICD-9 CM coding classification system

Clinical Documentation Specialist Resume Examples & Samples

Registered Nurse (RN) with active license to practice in the State of Maryland
3-5 years of experience with reviewing medical records as a DRG Analyst, Case Management, Utilization Review, or Quality and Outcomes
Effective interpersonal communication skills to interact with all levels of hospital personnel, including medical staff
Demonstrates effective written and verbal communication skills
Demonstrates critical-thinking skills and strong clinical knowledge
Is proficient in the use of computers to perform daily work including Microsoft Office (Word, Excel, PowerPoint, etc.), and other applications necessary to perform the CDS role such as an encoder or CDI workflow and reporting tool
Ability to collect and analyze data related to the CDI program
Is proficient in reviewing medical records and understanding pertinent clinical information
Member of AHIMA or ACDIS is recommended
Demonstrates good public speaking and presentation skills
Demonstrated knowledge and ability in the use of applicable personal computer systems and related software. Ability to learn specific HIM software applications
Demonstrated understanding of applicable medical terminology preferred. Ability to learn medical terminology required
Ability to operate routine office equipment such as photocopy and fax machines, PC’s and peripherals
Effective oral communication skills are necessary to interact and work with various levels of hospital staff in a courteous and effective manner

Clinical Documentation Specialist Resume Examples & Samples

3 years nursing experience required and experience in case management, health information management or utilization review preferred
Clinical documentation and/or clinical experience preferred with ICU, CCU or strong Med/Surg experience
Excellent organization, analytical, writing and interpersonal skills
Dependable and self-directed with excellent critical thinking, problem-solving and deductive reasoning skills
Excellent communication, computer, critical thinking, organization skills and multi-disciplinary tasks
Exhibits knowledge of clinical documentation requirements, DRG assignment, and clinical conditions and/or procedures
Understand and communicate differences between Medicare Part A and Part B guidelines and how they impact DRG assignments
Advance knowledge of Microsoft Office applications and troubleshooting computer problems
Understand and support compliant documentation management strategies that touches all the critical aspects of the hospital’s clinical documentation process
Demonstrates excellence in communication skills and interpersonal relations adheres to hospital policies and procedures and actively promotes the mission and core values of the organization.*
Assumes leadership role to assist in improving the overall quality and completeness of physician clinical documentation by performing admission and continued stay reviews using clinical documentation and coding guidelines and Milliman criteria.*
Supports timely, accurate, and complete documentation of clinical information used for measuring and reporting hospital and physician-based outcomes. *
Facilitates and obtains appropriate physicians documentation for any clinical conditions or procedures to support the appropriate severity of illness, expected risk of mortality, and complexity of care rendered to all patients with DRG-based payers.*
Demonstrates knowledge of DRG’s, clinical documentation requirements, and referral policies and procedures
Able to effectively educate Physicians, coders and others on clinical documentation, coding and reimbursement opportunities.*
Educates members of the patient care team regarding documentation guidelines, including attending physicians, allied health practitioners, nursing, and case management.*
Works independently in an effective and responsible manner.*

Clinical Documentation Specialist Resume Examples & Samples

Reflects HCA’s mission and values. Maintains sensitivity and commitment to HCA’s ethics and compliance principles (Code of Conduct) in his/her daily activities/conduct
Maintains and protects confidentiality
Performs initial concurrent review of assigned population consistent with Facility, Division, or Corporate program volume and frequency requirements
Performs follow-up reviews consistent with Facility, Division or Corporate program volume frequency requirements
Documents reviews and other pertinent information in designated systems by established deadlines
Uses clinical judgement to determine when and/or if a query is necessary
Queries physicians within established timelines via approved query forms for conflicting, imprecise, incomplete, illegible, or inconsistent documentation by requesting and obtaining additional documentation within the health record when appropriate
Uses clinical judgement to determine appropriate and relevant clinical indicators and to discern appropriate reasonable diagnostic options when formulating non-standard queries
Interacts with Physicians to complete/resolve queries prior to patient discharge
Collaborates with the Parallon HSC to assure accurate DRG assignment and billing
Performs reconciliation of CDI-assigned DRG against final coded DRG
Escalates DRG mismatches as appropriate per established protocols
Develops collaborative relationships to facilitate accomplishment of work goals
Possesses excellent interpersonal skills in building, negotiating, and maintaining crucial relationships
Demonstrates a willingness and ability to assist others
Uses critical thinking skills and independent discretion to analyze and interpret query trends/responses and to identify other education opportunities
Compiles, creates and delivers education to physicians and other key healthcare providers
Provides ad hoc education upon request
Achieves and maintains a minimum accuracy rate consistent with Facility, Division, or Corporate program requirements
Assists with the preparation and presentation of clinical documentation monitoring/trending reports for review with hospital and medical staff leadership
Represents the CDI function in other facility quality/monitoring activities
Demonstrates proficiency in current and emerging technologies
Completes all mandatory and assigned education by established deadlines
Attends scheduled meetings and continuing education programs
Seeks learning opportunities in areas of self-defined needs
Independently takes prompt proactive steps toward problem resolution
Associates Degree in Nursing required, BSN preferred
5-7 years in Case Management, Quality Review and/or other related clinical experience in an acute care environment
Current RN license required
Critical Care, ER, or OR experience preferred

Clinical Documentation Specialist Resume Examples & Samples

Minimum of 3 years clinical or inpatient coding experience in an acute care setting required; 5 years experience strongly preferred
Ability to stand and walk for periods of time is required in the performance of job responsibilities
Working knowledge of Medicare reimbursement system and coding structures/national coding guidelines

Clinical Documentation Specialist Resume Examples & Samples

Improves the overall quality and completeness of clinical documentation by performing admission/continued stay reviews by using the IODINE alert system and using clinical documentation specialist (CDS) guidelines and demonstrates knowledge of DRG payor issues, strategies, clinical documentation requirements, and referral policies and procedures
Facilitates modifications to clinical documentation to ensure that overall quality and appropriate reimbursement is received for the level of service rendered to all patients with a DRG based payor (Medicare, Medicaid, Blue Cross, Firstcare and self pay)
Processes discharges by updating the Navigant CDI monitor reflect any changes in status, procedures/treatment, and conferring with physicians to finalized diagnoses and conducts follow-up reviews of clinical documentation to ensure points of clarification have been recorded in the patient charts
Educates all internal customers on clinical documentation opportunities, coding
Performs other duties as assigned by the CDI supervisor and Vice –President
Continues professional growth by attending related seminars, webinars and workshops

Clinical Documentation Specialist Resume Examples & Samples

Concurrent analysis of in patient records to establish applicable diagnosis
Intervene with Clinical and Medical Staff to ensure documentation supporting applicable diagnosis
Educate Clinical and Medical Staff regarding documentation requirements specific to disease/diagnosis
Concurrently reviews selected admissions to identify most appropriate principal and secondary diagnosis to accurately reflect the patients severity of illness
Communicates with physicians and clinicians regarding missing, unclear or conflicting medical record documentation to clarify and obtain needed documentation
Develops clinician or physician education strategies to promote complete and accurate documentation and correct negative trends
Confers with Coders concurrently to ensure appropriate DRG and completeness of supporting documentation
Develops tools and coordinates audits for compliance
Identifies patterns and trends variance, identifying opportunities for improvement
Researches literature to identify new methods in development for disease components and documentation
Current RN Tennessee License
Bachelors Degree in Nursing or Healthcare related field preferred
Experience in Quality, Case Mgm, Clinical Audit or Data Abstraction necessary
Interpersonal Communication skills to motivate and manage an improvement process

Clinical Documentation Specialist Clinical Documentation Improvement East Orlando Resume Examples & Samples

Organizational, analytical, writing and interpersonal skills
Critical-thinking, problem-solving and deductive-reasoning skills
Knowledge of Pathophysiology, disease process and treatments
Basic computer skills - familiarity with Windows-based software programs
Knowledge of regulatory environment
Four - five years of acute care experience in med/surg, critical care, emergency room, or PACU
Knowledge of clinical documentation requirements that identify clinical conditions or procedures to support and enhance ICD-9 and ICD-10 coding. (Preferred)
BSN, MSN (Preferred)
Minimum of one year as a Clinical Documentation Specialist (Preferred)
Current active Florida State license as a Registered Nurse, Nurse Practitioner, or Physician’s Assistant
Certified Clinical Documentation Specialist (issued by the Association for Clinical Documentation Improvement Specialists (ACDIS)) (preferred)

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