Clinical Documentation Improvement Specialist Resume Sample
Shaun Williamson
788 O'Connell Spurs,
Detroit,
MI
+1 (555) 675 8161
Work Experience
Clinical Documentation Improvement Specialist
09/2015
-
PRESENT
Philadelphia, PA
- Interacts and communicates with Physician staff daily as needed – educating them in the process of clarifying documentation in the medical record; conducts follow up reviews of clinical documentation to ensure points of clarification have been recorded in the patient’s chart
- Facilitates accurate and complete documentation of medical conditions and treatment in patient records by completing the following
- Demonstrate successful completion of ongoing proficiency and compliance with regulatory requirements
- Occaional travel to the Community Based Outpatient Clinics is required
- Occasional travel to the Community Based Outpatient Clinics is required
- Conducts initial and follow-up concurrent reviews on targeted admissions for opportunities to clarify documentation in the medical record for accurate reflection of the acuity of the patient and justifying the level of care
- Coordinates with coding/HIM/UR and other departments to achieve a record that reflects the acuity of the patient and level of care provided
- Review medical record concurrently for documentation not yet in the record but supported by clinical indicators. Performs a thorough chart review to identify co-morbidities/complications, and documents these appropriately within the concurrent CDS worksheet. Determines the appropriate principle diagnosis of the patient
- Demonstrates an understanding of the importance of, and makes an effort to capture, all appropriate secondary diagnoses for quality rating purposes
Medical Record Technician Clinical Documentation Improvement Specialist
09/2008
-
05/2015
Detroit, MI
- Documents findings in workflow tools, noting all key information used in the tracking process
- Uses relationship building and strong communication skills to develop a rapport with providers to clarify information in the medical record
- Uses appropriate querying tools (templates) to capture needed documentation
- Queries the medical staff when necessary by written and/or verbal communication to obtain accurate and complete physician documentation that supports the patient condition(s) and treatment plan Provides education to physicians on the importance of complete documentation and key documentation concepts during regular physician meetings or on individually with physicians
- Reviews the progress of the CDI program by interpreting performance, process, and quality ratings reports. Able to identify areas of focus through report analysis
- Initiates and performs concurrent documentation reviews of selected inpatient records to clarify conditions/diagnoses and procedures where inadequate or conflicting documentation exists
- Facilitates documentation improvement methodology to support appropriate clinical coding for reimbursement and capture of the severity of patient diseases (case mix) treated at LGH. In addition, ensures completeness of clinical information used for reporting physician and hospital outcomes
Travel Clinical Documentation Improvement Specialist
01/2005
-
07/2008
Chicago, IL
- Timely follow up on all cases especially those with clinical documentation clarifications
- Interaction with physicians to facilitate complete and accurate documentation within the patient health record. Serves as a resource for physicians to help link ICD-10 CM coding guidelines and medical terminology to improve accuracy of final code assignment
- Educates internal customers on clinical documentation opportunities
- Develops and conducts ongoing CDI education for new staff, coders, physicians, residents, nursing, and allied health professionals
- Develops education program materials including online materials, handouts, overheads, PowerPoint presentations, etc
- Participation in CDI Taskforce meetings
- Identifies opportunities for CDI operational improvements
- Utilizes CDI software and EMR as tools to review the chart and develop concurrent queries capture improved clinical documentation
Education
University of Mount Union
2000 - 2004
Bachelor's Degree in Health
Professional Skills
- Graduation from an accredited program of nursing with 3+ years of ICU/CCU or Medical/Surgical experience, or certified RHIT or RHIA coding specialist with 3+ years of acute care coding knowledge and experience
- Excellent interpersonal skills including excellent verbal and written communication skills; proficient in and demonstrate excellent physician relations
- Utilize and demonstrate excellent critical-thinking, problem-solving and deductive-reasoning skills
- Excellent written and verbal communication skills; ability to write concisely and effectively when communicating with providers
- Effective interpersonal skills in order to effectively interact with all levels of hospital personnel both verbal and written
- Coding experience in a provider’s office, inpatient setting or a Medicare Advantage health plan setting – can be combined experience
- Experience ICD - 9 / 10 coding, preferably in a Managed Care setting, with strong attention to detail and high accuracy rate
How to write Clinical Documentation Improvement Specialist Resume
Clinical Documentation Improvement Specialist role is responsible for health, clinical, general, medical, interpersonal, software, terminology, microsoft, documentation, travel.
To write great resume for clinical documentation improvement specialist job, your resume must include:
- Your contact information
- Work experience
- Education
- Skill listing
Contact Information For Clinical Documentation Improvement Specialist Resume
The section contact information is important in your clinical documentation improvement specialist resume. The recruiter has to be able to contact you ASAP if they like to offer you the job. This is why you need to provide your:
- First and last name
- Telephone number
Work Experience in Your Clinical Documentation Improvement Specialist Resume
The section work experience is an essential part of your clinical documentation improvement specialist resume. It’s the one thing the recruiter really cares about and pays the most attention to.
This section, however, is not just a list of your previous clinical documentation improvement specialist responsibilities. It's meant to present you as a wholesome candidate by showcasing your relevant accomplishments and should be tailored specifically to the particular clinical documentation improvement specialist position you're applying to.
The work experience section should be the detailed summary of your latest 3 or 4 positions.
Representative Clinical Documentation Improvement Specialist resume experience can include:
- Utilizes excellent interpersonal skills in developing/maintaining collaborative working relationships
- Clinical experience working as an RN in an inpatient hospital, acute care setting OR Medical Graduate with CDI experience
- Clinical experience working in an inpatient hospital, acute care setting – ICU, Critical Care, Med/Surg, ED and/or Home Care experience
- Coding experience with ICD-10 CM and PCS
- Clinical Documentation Improvement experience – conducting reviews, sending queries and educating physicians
- RN or Medical Graduate with at least 1+ year of Clinical Documentation Improvement experience – conducting reviews, sending queries and educating physicians
Education on a Clinical Documentation Improvement Specialist Resume
Make sure to make education a priority on your clinical documentation improvement specialist resume. If you’ve been working for a few years and have a few solid positions to show, put your education after your clinical documentation improvement specialist experience. For example, if you have a Ph.D in Neuroscience and a Master's in the same sphere, just list your Ph.D. Besides the doctorate, Master’s degrees go next, followed by Bachelor’s and finally, Associate’s degree.
Additional details to include:
- School you graduated from
- Major/ minor
- Year of graduation
- Location of school
These are the four additional pieces of information you should mention when listing your education on your resume.
Professional Skills in Clinical Documentation Improvement Specialist Resume
When listing skills on your clinical documentation improvement specialist resume, remember always to be honest about your level of ability. Include the Skills section after experience.
Present the most important skills in your resume, there's a list of typical clinical documentation improvement specialist skills:
- Acute care hospital clinical RN experience with hospital Case Management experience or CDI experience OR Medical Graduate with CDI experience
- Experience ICD-9 / 10 coding, preferably in a Managed Care setting, with strong attention to detail and high accuracy rate
- Extensive clinical knowledge and understanding of pathology/physiology; best demonstrated by clinical experience in hospital setting
- Customer Service skills in a health care setting
- Experience in critical care, general medical and/or surgical nursing, and experience in educational presentations beneficial
- Prior CDI consulting experience
List of Typical Experience For a Clinical Documentation Improvement Specialist Resume
1
Experience For Medical Record Technician Clinical Documentation Improvement Specialist Resume
- Utilizes hospital information technology software to collect, track, and report outcomes and the effectiveness of the data
- Working knowledge of ICD10 CM & PCS, CPT, MS-DRGs, APR-DRGs
- Assists the Manager of Clinical Quality & Coding, with research, analysis, and response to inquiries regarding compliance, coding, and inappropriate coding
- Ensures accuracy and completeness of clinical information used for measuring and reporting physician and hospital outcomes
- Utilizes software as a resource in ensuring accurate documentation. Tracks responses and trends completion of concurrent queries
- Educates internal customers on clinical documentation opportunities, coding and reimbursement issues, as well as performance improvement methodologies
- Create custom Instructor-Led Training Sessions to meet specific and unique client needs based on CDI client request or audit results
2
Experience For Ambulatory Clinical Documentation Improvement Specialist Resume
- Monitors and evaluates effectiveness of concurrent coding outcomes at designated intervals. Report concurrent coding outcomes to hospital departments and committees at designated intervals. Communicates information effectively
- Demonstrates responsibility for personal development by participating in continuing education offerings. Maintains competence related to MS-DRG assignment, documentation requirements, and coding guidelines
- Nursing experience in the acute care setting
- Demonstrates professionalism when communicating with CDI and HIM staff ing resolving discrepancies
- Effective and appropriate communication with physicians and nurses
- Maintains accurate records of review activities
- Facilitates modifications to clinical documentation to support appropriate reimbursement for the level of service rendered to all patients and to ensure completeness and accuracy of the medical record
- Conducts follow-up reviews of clinical documentation to ensure points of clarification have been recorded in the patients chart; Works collaboratively with coding staff to assign DRGs; Tracks and trends response to CDI
- Participates in internal and external Team Meetings
3
Experience For Travel Clinical Documentation Improvement Specialist Resume
- 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
- Works closely with designated Health Information Service Center (HSC) coding staff to assure documentation of discharge diagnoses and any co-existing co-morbidities are a complete reflection of the patient’s clinical status and care
- Evaluate documentation within a patient’s medical record to identify conflicting, incomplete, or nonspecific provider documentation impacting the appropriate assignment of the principal diagnosis, pertinent secondary diagnoses, and procedures for accurate DRG assignment, risk of mortality, and severity of illness
- Skills: Proficient computer skills for Windows Microsoft Office Applications (Word, Excel, Power Point)
- Ensures improved documentation to support appropriate coding, reimbursement and quality data
4
Experience For Risk Adjustment Clinical Documentation Improvement Specialist Resume
- Education: Bachelors of Science in Nursing
- Provides Working DRG lists to Care Coordination
- Preparation of reports related to CDI activities and outcomes
- Attendance at WebEx or teleconference meetings and/or education sessions as necessart
- Develops and presents basic, intermediate and advanced education for CHS personnel, as follows
- Engages and consults with Physician Advisor / VPMA when needed, per the escalation process, to resolve provider issues regarding answering clarifications and participation in the clinical documentation improvement process
- Continuously evaluates the quality of clinical documentation to identify incomplete or inconsistent documentation for inpatient encounters that impact the code selection and resulting DRG groups and payment
- Communicates with attending physician either verbally or through written methodology to validate observations and suggest additional and/or more specific documentation as it relates to coding compliance, medical necessity and documentation improvement
5
Experience For Clinical Documentation Improvement Specialist Rehab Resume
- Coordinates and conducts regular meeting with HIM Coding Professionals to reconsolidate DRGs, monitor retrospective query rates and discuss questions related to
- Provides expert level review of inpatient clinical records within 24 - 48 hours of admit; identifies gaps in clinical documentation that need clarification for accurate code assignment to ensure the documentation accurately reflects the severity of the condition and acuity of care provided
- Ensures effective utilization of Optum® CDI 3D Technology to document all query activity
- Provides educational opportunities with physicians on a daily basis
- Three years of previous clinical acute care nursing experience medical/surgical experience to include critical care in conjunction with an expanded knowledge of Diagnosis-Related Groups (DRG)
6
Experience For Clinical Documentation Improvement Specialist K Sign On Resume
- Creating and maintaining Instructor - Led Training, eLearning training, and Live Webinars
- Collaborate across various levels of resources
- Assist Education Director with solution development and sales support of CDI education through proposal development, responding to RFPs, development and delivery of client presentations
- Evaluates and analyzes medical records concurrently for proper documentation. This review includes new admissions to the facility, as well as re-reviews every two – three days until the patient is discharged
- Manages and trends data collection for an assigned hospital / facility/ specialty
- The CDI Specialist is the primary source to verify diagnoses in the medical record for proper DRG coding. When symptoms in the medical record require further documentation, the CDI Specialist queries the physician for a specific diagnosis/procedure for more accurate DRG coding
- Collaborates with HIM Coders, clinicians and physicians to ensure documentation that supports the diagnosis and treatment of the patient is timely and accurate documentation
7
Experience For Clinical Documentation Improvement Specialist Resume
- Provides on-going training and education to the clinicians and physicians during 1:1, physician group, performance improvement and ad hoc meetings
- Collaborates with Quality and Case Management Department by reviewing medical records that are not meeting standards, and assists with the development of action plans to improve documentation for peer review of medical and nursing staff’s documentation
- Performs 100% Comprehensive concurrent coding quality reviews for providers in each market for all CCM lines of business (NP, PA, MD) (CCR)
- Assists the Director and the hospital team in with preparation, coordination and response to areas of documentation improvement
- When fall outs of accepted criteria occur, the CDI Specialists reviews the information with the physicians, clinicians, HIM and Quality Department
- Provides expert level review of submitted visit notes; identifies gaps in clinical documentation that require clarification for accurate code assignment to ensure the documentation accurately reflects the severity of the condition
- The Clinical Documentation Improvement Specialist conducts a comprehensive concurrent review of clinical documentation within the medical record to achieve accurate and detailed documentation
8
Experience For Medical Record Technician Clinical Documentation Improvement Specialist Resume
- Knowledge of medical terminology, ICD-10-CM and CPT-4 codes
- Provides expert level review of inpatient clinical records within 48 hours of admit; identifies gaps in clinical documentation that need clarification for accurate code assignment to ensure the documentation accurately reflects the severity of the patient condition and acuity of care provided
- Ensures effective utilization of the Optum360 CAC software
- Actively engages with healthcare team on the assigned patient unit to continually evaluate and spearhead clinical documentation improvement opportunities
- Conducts physician chart audits (including research and presentation). Assesses and interprets whether the coding assigned by the client was properly assigned based upon review of the medical documentation and application of the coding guidelines
9
Experience For Ambulatory Clinical Documentation Improvement Specialist Resume
- Implement education, and provide formal training to Lifeprint providers and staff as needed regarding coding compliance, documentation guidelines, usage of CCA long and short form, HCC education and Medicare/Medicaid regulations by proactively providing solutions to meet the needs of the Lifeprint provider
- Work independently and rely on professional discretion and judgment; as well as a professional representation of Lifeprint
- Responsible for maintaining current knowledge of coding guidelines and relevant federal regulations through the use of current ICD-10 CM book, and other pertinent materials
- Create Policy and Procedures to be used within the department to support Best Practices
- Reviews medical records and identifies potential gaps in clinical documentation for specified patient types and payer populations from admission throughout the hospitalization
10
Experience For Travel Clinical Documentation Improvement Specialist Resume
- Assigns working DRG based upon selection of principal diagnosis, complications or co-morbid conditions and /or valid OR procedures, including capture of POA indicators
- Queries physicians as necessary within established timelines for conflicting, imprecise, incomplete, illegible, or inconsistent documentation by requesting and obtaining additional documentation within the health record when appropriate
- Performs reconciliation of assigned DRG against final coded DRG
- This is an office based role located at St. John's Pleasant Valley Hospital in Camarillo, CA.
- Onsite position at St. John's Regional Medical Center in Oxnard, CA
- Provide pre-visit risk adjustment audit reviews using CMS's guidelines and HCC methodology to ensure accuracy, specificity, and appropriateness of ICD-10 codes and documentation communicating to the provider via EMR notification/alert
List of Typical Skills For a Clinical Documentation Improvement Specialist Resume
1
Skills For Medical Record Technician Clinical Documentation Improvement Specialist Resume
- Experience/Education Combination - Equivalent combinations of experience and education are qualifying
- Acute care hospital clinical RN experience OR Medical Graduate with CDI experience
- Learn/develop and fine-tune the skills necessary to perform optimally as a Clinical Documentation Specialist
- Acute care hospital clinical RN experience OR Medical Graduate with CDI experience and CDI certification (CCDS, CDIP)
- Experience / working knowledge of CMS Risk Adjustment and HCC Coding preferably in a Managed Care Setting
- Acute care Clinical Documentation Improvement experience - conducting reviews, sending queries and educating physicians
- Clinical Documentation Improvement experience - conducting reviews, sending queries and educating physicians
2
Skills For Ambulatory Clinical Documentation Improvement Specialist Resume
- Five years of acute care clinical setting nursing experience
- Experience of utilizing ICD-10 CM coding classification and guidelines
- Active coding experience with ICD diagnosis coding
- Clinical experience working in an inpatient hospital, acute care setting
- Active CMS HCC Coding / Auditing experience
3
Skills For Travel Clinical Documentation Improvement Specialist Resume
- Clinical experience working in an inpatient hospital, acute care setting
- Possesses the ability to develop and present effective education utilizing a variety of media platforms
- Provider education experience – communicating directly with providers
- Clinical knowledge and experience working in a Trauma unit
- Experience working with Optum360 CAC or Cerner
- Non-RN, Inpatient coding experience would be required
4
Skills For Risk Adjustment Clinical Documentation Improvement Specialist Resume
- Direct Acute Care nursing experience required
- Direct Acute Care clinical nursing experience required
- Experience as ICD coding Auditor
- Experience with Risk Adjustment/HCC Coding Model
- Five (5) years experience in nursing or other clinical area
- Experience delivering in person classroom and one on one education sessions
- CAC experience - computer assisted coding
- Active, unrestricted RN license OR a Medical Graduate with CDI experience
5
Skills For Clinical Documentation Improvement Specialist Rehab Resume
- Clinical Documentation Improvement Experience
- Critical care (ICU/CCU/ER/OR) experience in an acute-care environment is required
- Working knowledge of federal, state and payer-specific regulations and policies pertaining to documentation, coding and reimbursement
- Recognizing problems identified during chart review and refer appropriate cases to peer review
- Understanding and communicating differences between Medicare Part A and Part B guidelines and how they impact MS-DRGs and APR-DRGs
- Working knowledge of regulatory coding guidelines
- Working knowledge of coding principles and guidelines
6
Skills For Clinical Documentation Improvement Specialist K Sign On Resume
- Working knowledge of reimbursement systems and regulatory coding systems (e.g. ICD-9CM, HCPCSA, MS-DRGs)
- Finalizing documentation and providing feedback to team members based on findings. This function can account for approximately 5% of the CQA time
- Formulating clinically credible documentation clarifications in the form of queries
- Communicating with others clinical or non-clinical staff/MDs to resolve discrepancies
- Working knowledge of data analysis and personal computer spreadsheet software
- Working knowledge of impatient admission criteria
7
Skills For Clinical Documentation Improvement Specialist Resume
- Coding certification with a preference for CCS, CCS - P CPC, RHIA, RHIT
- Delivering onsite and Webinar education sessions for providers and CDIS
- Provide feedback and present solutions, to the Manager of Clinical Coding and Quality, regarding trends or patterns noticed in provider coding
- Is responsible for maintaining a current knowledge of the nursing practices contemporary to the legal framework of the Nurses Practice Act,
- Uses the DMAIC cycle and assists in educating and coaching staff, managers and physicians in its use
- Conducts chart review of OptumCare of Arizona members - accomplished by traveling to the individual practices (185 Total) and performing the audit onsite
8
Skills For Medical Record Technician Clinical Documentation Improvement Specialist Resume
- Utilize HCC coding bank to capture, identify, and evaluate any HCC codes that need to be re-documented for the current audit year
- Current Registered Nurse Licensure from the Maine State Board of Nursing
- Services to be rendered are timely and performed in the most appropriate setting
- Current licensure as a Registered Professional Nurse, issued by the PA State Board of Nursing
- Certified Coding Specialist (CCS) OR Certified Clinical Documentation Specialist (CCDS) OR Certified Documentation Improvement Practitioner (CDIP)
- CCS (Certified Coding Specialist)
- Adventist Health Care online learning
9
Skills For Ambulatory Clinical Documentation Improvement Specialist Resume
- Limited Documentation Reviews for the purpose of creating educational content
- Assists with the development and implementation of performance improvement activities according to the Virtua Quality Plan
- Knowledge of clinical documentation requirements that identify clinical conditions or procedures
- Applies the skills necessary to concurrently/retrospectively review (initial & extended stay) charts, improve documentation based on diagnosis and clinical findings with
- Accurate and timely record reviews
- Generates reports internally on required functions (e.g., productivity, core measures, outcomes metric, etc., utilizing report formats to display the use of aggregate and trended data.)
- Responsible for organizing and planning training/education for assigned providers and administrative staff on quality measures, discrete documentation and optimization of EMR's, utilization of tools provided by UTSW, Risk Adjustment, ICD 10 codes, and HHC methodology
- Identify areas of documentation/coding that needs improvement and organizes, as needed, monthly training sessions with assigned providers and/or their administrative staff
10
Skills For Travel Clinical Documentation Improvement Specialist Resume
- Maintains auditing skills for documentation quality
- MS Office; Advanced PC skills
- Medicare Risk Adjustment experience
- HS Diploma or higher or significant equivalent work experience (3+ years)
- Experience in case management and / or critical care
- One (1) year of experience equivalent to Clinical Documentation Improvement Specialist I
- Three (3) years acute care hospital experience required
- Previous experience with criteria-based chart review such as case management, utilization management, managed care, or quality improvement
- Provide pre-visit quality audits for targeted quality measures communicating needed measures to provider via EMR notification/alert
List of Typical Responsibilities For a Clinical Documentation Improvement Specialist Resume
1
Responsibilities For Medical Record Technician Clinical Documentation Improvement Specialist Resume
- License: LPN/RN/NP/MD/PA with prior CDI hospital based CDI Education experience
- Has developed and facilitated physician education and CDIS education, and has experience in working directly and communicating with physicians
- Optum CAC experience (Computer Assistant Coding)
- Acute care hospital clinical RN experience OR Medical Graduate
- Well-developed written and oral communications skill
- Experience as an acute care hospital clinical RN OR a Medical Graduate
2
Responsibilities For Ambulatory Clinical Documentation Improvement Specialist Resume
- Familiar with DRG’s and coding guidelines and how documentation impacts DRG assignment
- Interpret and analyze all information in a patient's health record, including laboratory
- Regulatory and third party requirements as it relates to documentation improvement
- Review and interpret clinical information
- Teamwork – balances team and individual responsibilities; objective and open to other’s views; gives and welcomes feedback; contributes to positive team spirit; puts success of team above own interest
- Note: Education cannot be substituted at the GS-9 level
- Certified Coding Specialist or Certified Registered Nurse Practitioner or Doctor of Podiatric Medicine or Medical Doctor or Registered Health Information Administrator or Registered Health Information Technician or Registered Nurse
- Graduation from an accredited RN program with recent hospital experience or RHIA or RHIT certification
- Experience in a similar CDI capacity
3
Responsibilities For Travel Clinical Documentation Improvement Specialist Resume
- Knowledge of care delivery documentation systems and related medical records documents
- Coding Certification from AAPC or AHIMA, (CPC, CPC-H, CPC-P, RHIT, RHIA, CCS, CCS-P) OR LPN willing to obtain coding credential from AAPC or AHIMA within 12 months of hire
- Acute care hospital clinical RN experience OR Foreign Medical Graduate with CDI experience and a CDI certification (CCDS, CDIP)
- Knowledge of care delivery documentation and related medical record documents
- Complete assignments in a timely manner despite fluctuations in workflow
- Knowledge of email, Word Excel, data entry and data retrieval systems, Encoder and internet
- Knowledge of pathophysiology, disease processes and treatments
4
Responsibilities For Risk Adjustment Clinical Documentation Improvement Specialist Resume
- Coding Certification from AACP or AHIMA professional coding association (CPC, CPC-H, CPC-P, RHIT, RHIA, CCS, CCS-P) or RN / LPN with ability to obtain coding certification from AHIMA or AAPC within 12 months of hire
- Direct experience in working as a CDI Specialist or in development of CDI program in the acute care setting and understanding of CDI program infrastructure, workflow and reporting/metrics
- CDI Specialist Certification through ACDIS or AHIMA
- RN required; Texas State RN license or compact license is accepted
- Travel locally to provider practices (75%) in Phoenix area
- Proficient in Microsoft Office (e.g. Word, Excel, Outlook)
- Knowledge of age-specific patient needs and the elements of disease processes and related procedures
- RN with current Maryland Licensure
- Able to interact positively with clients and understand their needs in the HIM and medical records of healthcare
5
Responsibilities For Clinical Documentation Improvement Specialist Rehab Resume
- Demonstrated good nurse-physician relationships in the past and the ability to maintain those going forward. Assertive personality traits to facilitate ongoing physician communication
- On call shift coverage as required by department
- Location/Facility – Baylor Scott & White at Temple or Round Rock
- Location/Facility – Baylor Scott & White Memorial Hospital, Temple TX
- Correlates with available procedure and diagnosis codes
- Supports assignment to the proper DRG
- Results in the assignment of an appropriate risk of mortality score
- Compliance with regulatory, state and federal requirements
6
Responsibilities For Clinical Documentation Improvement Specialist K Sign On Resume
- Medical necessity and appropriateness with use of medical ISD-A criteria
- Maximal benefit coverage via compliance with certification required
- Managed care contract requirements
- Specialty/Department/Practice –Clinical Documentation Accuracy Program
- Refer to the required documents section to ensure a complete application packet is provided
- Knowledge of coding rules and requirements to include clinical classification systems (such as current versions of ICD and CPT), complication or comorbidity/major complication or comorbidity (CC/MCC), Medicare Severity Diagnosis Related group (MS-DRG) structure, and Present on
- Track and report documentation improvement activities
7
Responsibilities For Clinical Documentation Improvement Specialist Resume
- During review, identify and trigger to the care managers those patients identified as clinically and chronically (high to medium risk) complex patients needing care management intervention
- Review for compliance and completion of targeted quality measures required for the management of capitation/risk and ACO population
- Works collaboratively with physicians, physician extenders, nurses, case managers, and medical records coding team to identify opportunities to clarify documentation in patient records
- Conducts initial and extended-stay concurrent reviews on all selected admissions and documents findings in CDIS application for auditing and tracking
- Queries the medical staff to obtain accurate and complete physician documentation that supports severity of illness (SOI), risk of mortality (ROM) and reimbursement
- Demonstrates an understanding of the importance of capturing all potential co-morbidities, complications, and secondary diagnoses for quality reporting and other data collection purposes
- Participates in development, implementation, and roll-out of electronic documentation tools to enhance provider documentation. Use of point of care tools to capture complete, accurate and effective documentation, while ensuring regulatory compliance
8
Responsibilities For Medical Record Technician Clinical Documentation Improvement Specialist Resume
- CDI experience
- Current active State license as a Registered Nurse, Nurse Practitioner, or Physician’s Assistant
- CCDS (Certified Clinical Documentation Specialist) certification
- Achieve a 70% or greater on JA Thomas Clinical Competency Pre-Assessment
- Achieve a 70% or greater on the JA Thomas Annual Competency
9
Responsibilities For Ambulatory Clinical Documentation Improvement Specialist Resume
- Commuter expenses reimbursable
- RN with active Indiana license
- At least five (5) years acute health care nursing experience or BSN with at least three (3) years acute health care nursing experience (with at least one (1) of those years in clinical documentation)
- Experience with Inpatient CDI
- Coding and CDI
- Knowledge of medical record organization
10
Responsibilities For Travel Clinical Documentation Improvement Specialist Resume
- AHIMA ICD - 10 - CM / PCS Trainer credential
- Registered Nurse (RN) or Registered Health Information Management Administrator (RHIA)
- Coding Certification from AACP or AHIMA professional coding association (CPC, CPC-H, CPC-P, RHIT, RHIA, CCS, CCS-P, CRC) or RN / LPN with ability to obtain coding certification from AHIMA or AAPC within 12 months of hire
- Acute care hospital clinical experience
- Dignity Health experience
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