Clinical Documentation Specialist Resume Sample
Collin Ernser
3489 Ayden Valleys,
Philadelphia,
PA
+1 (555) 402 9718
Work Experience
Clinical Documentation Specialist
08/2016
-
PRESENT
San Francisco, CA
- 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
- Performs clinical evaluation of the medical record including physician documentation and clinical results
- Facilitates modifications to clinical documentation through concurrent interactions with physicians and
- Ensures the accuracy and completeness of clinical information used for measuring and reporting physician and medical center outcomes. Tracks response to CDS and trends completion of Navigant CDI monitor
- Assists in screen processes, making referrals, interacting with case managers and clinical nurse specialists to ensure continuity of patient care
- Maintains appropriate non-leading queries concurrently to physicians
- Educates physicians, case management, charge nurse and other departments as needed
Lead Clinical Documentation Specialist
06/2014
-
06/2016
Detroit, MI
- Collaborates with leadership to assess the learning needs and competencies of the department and identify issues for education and training to address specialty specific documentation needs
- Designs, delivers and assesses learning activities and curriculums related to competencies, departmental policies, regulatory requirements, and the use of information technologies
- Coordinates ongoing clinical documentation provider education across the JPS Health Network and community
- Collaborates with physicians, leaders and the CDS staff to address specialty specific documentation needs and provides clinical documentation education
- Provides education plans for all levels of CDS at both a group and individual level. Develops and executes clinical education to the CDS and coding staff and provides continuous feedback on directed education and specific needs
- Participates in the interviewing and hiring of new staff and execute new hire orientation. Acts as a preceptor and ensures follow up as needed
- Collaborates with the Quality department to identify specialty specific documentation needs to improve reported metrics. Develops and implements educational programs that can improve the documentation and coding of specific metric driven data
Risk Adjustment Clinical Documentation Specialist
06/2011
-
02/2014
Boston, MA
- Assist with IT strategy and implementation with Epic team and external software vendors. Creates joint standards for chart review and querying by diagnosis
- Reviews query type trends and report out on physician query response times. Monitors CDS audit trends and ensures compliant and effective queries
- Identifies areas where clinical documentation and coding can improve workflow. Develops policies/guidelines to assure a smooth and compliant CDI program that supports the education and development of the department. Responsible to develop and update department clinical guidelines and develop new queries and update current queries as needed
- Conducts initial concurrent review process and subsequent reviews for all selected admissions to initiate the process, documenting findings on Diagnosis Related Group (DRG) worksheets. Also identifies other key pathways or quality indicators, as appropriate
- Identifies and records principal and secondary diagnoses, principal procedures and assigns a working DRG. Collaborates with physician, nurse, care managers, and HIM inpatient coders as needed
- Identifies need to clarify documentation in the medical record and initiates communication with physician, nurse, or care managers by utilizing the appropriate Documentation Request tools in order to capture the documentation in the medical record that supports patient’s severity of illness, risk of mortality and justifies the treatment provided
- Performs daily Clinical Documentation Improvement Program tasks including extensive medical record review, identification of opportunities for documentation improvement, formulation of clarifications, as well as compliant and effective communication with physicians and other clinical staff to obtain needed documentation
- Demonstrates knowledge of DRG methodologies and coding guidelines related to clinical documentation improvement and is able to effectively apply those guidelines and identify opportunities
- Formulates clinically credible and compliant documentation clarifications and addresses clarifications and compliance with physicians, clinical staff and HIM coding professionals as indicated
Education
American Sentinel University
2005 - 2010
Bachelor's Degree in Nursing
Professional Skills
- Demonstrate strong organizational skills with demonstrated leadership ability
- Strong interpersonal skill and communication skills required
- Experience One or more years of experience as an RN in a Home Health and/or hospice setting; Utilization Review, clinical coding and OASIS-C review experience
- Hospital clinical experience with 2 years clinical chart review experience OR 5 years inpatient coding experience
- Demonstrates highly developed problem solving skills and self-directed, motivated behavior
- Good organizational skills including the ability to prioritize work
- Excellent interpersonal skills to build effective partnering relationships with physicians, nurse staff and hospital management staff
How to write Clinical Documentation Specialist Resume
Clinical Documentation Specialist role is responsible for interpersonal, clinical, computer, documentation, medical, organizational, software, collaboration, basic, utilization.
To write great resume for clinical documentation specialist job, your resume must include:
- Your contact information
- Work experience
- Education
- Skill listing
Contact Information For Clinical Documentation Specialist Resume
The section contact information is important in your clinical documentation 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 Specialist Resume
The section work experience is an essential part of your clinical documentation 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 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 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 Specialist resume experience can include:
- Understands and communicates differences between Medicare and commercial payer guidelines and how they impact DRG assignment and other data reporting requirements
- Strong interpersonal skills and communication skills required
- Effectively manages multiple priorities and demonstrates persistence in achieving targets
- Evidence of strong communication and negotiation skills
- Demonstrates analytical and decision making skills
- Effective utilization of nursing assessment and clinical process skills
Education on a Clinical Documentation Specialist Resume
Make sure to make education a priority on your clinical documentation 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 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 Specialist Resume
When listing skills on your clinical documentation 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 specialist skills:
- Excellent observation, analytical thinking, problem solving, teaching, and verbal and written communication skills
- Good computer skills are required, working knowledge of MS Word, Excel, and PowerPoint is required
- Good critical thinking skills, able to assess, evaluate and teach
- Possesses strong communication skills adaptable to a wide variety of interpersonal encounters with the entire healthcare team
- Strong computer/PC skills essential
- Excellent interpersonal skills to develop relationships necessary to influence physician documentation processes
List of Typical Experience For a Clinical Documentation Specialist Resume
1
Experience For Senior Clinical Documentation Specialist Resume
- Effectively using business and clinical data in accordance with KCI policies
- Interpersonal skills and ability to work with all levels of physicians, advanced practice providers and staff
- Effectively follow SOPs, policies, and cGMPs
- Demonstrate ability to work accurately, follow instructions, and handle multiple priorities
- Working knowledge of computers, experience with electronic documentation and ability to learn home care software package
- Active RN license in good standing required
- Auditing or medical review experience
- Experience in utilizing Interqual and/or E&M guidelines no less than 2 years
2
Experience For Lead Clinical Documentation Specialist Resume
- Recommends timely and effective strategies for revising or correcting clinical documentation to resolve problems and improve compliance
- Contributes to financial integrity of the department through identification, implementation and evaluation of cost effective practices
- Five years of current clinical experience preferably in critical care
- Clinical Documentation experience required
- Identifying additional wounds with designated Post Acute Clinical Providers
- Participates in ongoing training and education regarding current industry standards and trends in behavioral healthcare and third party reimbursements
- Medical Records Coding: Works closely with HIM coding staff to assure documentation of discharge diagnosis (es) and any co-existing
3
Experience For Risk Adjustment Clinical Documentation Specialist Resume
- Completes Continuing Education requirements as determined by licensing/credentialing body
- Collaborates with Regional Shared Services (Patient Financial Services) to resolve billing and utilization issues affecting reimbursement
- Ensures the accuracy and completeness of clinical information used for measuring and reporting physician and hospital outcomes
- Maintains an ongoing record of the results of each chart review including responses to all interventions
- Maintains professional competency by keeping abreast of new coding issues and guidelines
4
Experience For Clinical Documentation Specialist International Md-days Resume
- Supports timely accurate and complete documentation of clinical information used for measuring and reporting physician and hospital outcomes data
- Meets medical center’s Core Values including interpersonal communication and professional conduct expectations
- Tracks and follows up on documentation or charge issues to facilitate coding in a timely fashion
- Develop and present on-going TMF and documentation education for Clinical Operations staff
- Train varying Clinical Operations roles on TMF system use
- Improves the overall quality and completeness of clinical documentation by ensuring accuracy and completeness of clinical information
- Educates all internal customers on compliant documentation responsibilities, coding and reimbursement issues
- Tracks participation in orientation, OASIS, and ongoing educational programs
- Acts as a lead super-user for clinical documentation system and leads development and delivery of training related to clinical documentation
5
Experience For Clinical Documentation Specialist Clinical Documentation Improvement East Orlando Resume
- Proficiency in using Microsoft Office products such as, Word, Excel, PowerPoint, Visio, etc
- Develop and manage customer relationships creating loyalty with Clinical Providers
- Review medical records for conflicting, incomplete, or non-specific documentation by provider
- Participates in Coding/CDI Task Force Meetings
- Teaches MDC methodology to the client, identifying CDI opportunities for documentation clarification
- Leads CDI-applicable presentations to Ancillary department (Physical Therapy, Nursing, Dietary, etc.)
6
Experience For Contingent Clinical Documentation Specialist Resume
- · Graduation from a program of nursing, BSN or Graduate of Health Information
- Provides support for insurance verification, billing, A/R, and facility UR departments to follow up on benefit, authorization, and non-payment issues as needed
- Proficiency in navigating the Electronic Health Record (EHR)
- Able to focus in work areas near clinicians and staff performing telephone calls
- Working member of an audit inspection-ready R&D paper and electronic Archives, responsibilities include
- Conduct quarterly electronic laboratory and paper notebook training
- Maintains continuing education and credentials, if applicable, for required job classification
- Participates in the planning for assigned inter/intra departmental meetings and presentations
- Maintains a library of information beneficial to coding and documentation
7
Experience For Mkt Manager Clinical Documentation Specialist Resume
- Familiar with CPT, ICD-9, ICD-10 and DRG coding
- Clarifies clinical documentation through extensive interaction with physicians, nursing staff and other patient caregivers
- Registered Nurse (RN) - Minnesota Board of Nursing (current licensure)
- Work in varying degrees of temperature (heated or air conditioned)
- Supports Managers in training efforts for new personne
- Clinical understanding of pharmacology, pathophysiology, labs , radiology and disease processes
- Master’s of Science in Nursing (MSN)
8
Experience For Clinical Documentation Specialist Case Management Resume
- Understand and support CDI/CDMP documentation strategies (upon completion of training)
- Understand and communicate differences between Medi-Cal and other payors, guidelines and how they impact DRG assignments (upon completion of training)
- In-depth understanding of the patient care environment
- Graduate of an accredited Nursing, Health Information Technology program, or other applicable education program
- · In addition, the following are highly desired: RHIT, RHIA, CDIP, CCDS, CCS and ICD-10 certification or designation
- Exercise sound judgment, eliciting support and cooperation from co-workers
9
Experience For Clinical Documentation Specialist Days Fountain Valley Resume
- Engage in self-appraisal and continuous learning
- Develops and delivers education to physician and clinical staff related to clinical documentation improvement
- Input data into computer required
- Understands prospective payment systems, the impact of complication/comorbidities (CC's/MCC's), in addition to risk of mortality and severity of illness. Understands payer coding and billing requirements, including National Correct Coding Initiatives (NCCI)
- Abstracts additional health record information for use in data collection, retrieval of health care statistics, maintenance of required disease and operative indexes, quality assurance monitoring activities, and data base maintenance for use by hospital administration, committees, medical staff, and accrediting, licensing, and regulatory agencies
- Responds to and resolves automated edits in 3M (ie, Audit Expert, OCE, CCI, etc.). Validates charges, when necessary, by comparing charges with health record documentation. Refers accounts to appropriate departments for action when needed, such as resolving edits, correcting charges, obtaining missing documentation, etc
- Maintains up-to-date knowledge of coding guidelines and regulations. Participates in educational opportunities to enhance knowledge of coding and reimbursement systems. Obtains/maintains certification from AHIMA or AAPC to validate coding skills
- Maintains a working knowledge of applicable Federal, State and local laws and regulations, the Compliance Accountability Program, Code of Ethics, as well as other policies and procedures to reflect adherence with honest, ethical and professional behavior
10
Experience For Clinical Documentation Specialist, HIM DV Resume
- Reviews inpatient records throughout the hospitalization – assessing orders, patient class, current treatment plan and documentation recorded for “gaps” in vermicular when compared to treatment plans and the documentation in the record
- Demonstrates and applies knowledge of AHA’s Inpatient Coding rules (i.e. Coding Clinic) and serves as expert in clinical documentation knowledge to Coder II (inpatient coder) with collaborative process on querying clinical staff
- Identifies patients appropriate for the Hospital Quality Measures, and prompts physician, RN, and ancillary clinical support for clinical documentation according to the accepted standards
- Reports trends or gaps in missed charge capture to Senior Manager, Hospital Coding and Billing
- Execute quantitative analysis using Crystal Reporting and Excel
- Identifies trends and/or opportunities to improve clinical documentation; presenting opportunities. In addition, potential solutions to the HIM management team
- Identifies trends and/or opportunities to improve clinical documentation; presenting opportunities in addition, potential solutions to the HIM management team
- Uses expert knowledge of software tools to appropriately query physicians for documentation
List of Typical Skills For a Clinical Documentation Specialist Resume
1
Skills For Senior Clinical Documentation Specialist Resume
- Demonstrated ability to deal effectively with customers, employees and business contacts, while conveying a positive service oriented attitude
- Outstanding customer service skills and a high attention to detail
- Effectively manages and utilizes electronic, automated tools and/or methods for developing OASIS training material and ongoing educational needs of all staff
- Demonstrates skill in developing and maintaining relationships with key stakeholders (physicians, coders, managers)
- Highly developed organization, critical thinking and analytical skills
- Intermediate computer skills in data entry, word processing and spreadsheet utilization
2
Skills For Lead Clinical Documentation Specialist Resume
- Validates appropriate MS-DRG. Validates charges, when necessary, by comparing charges with health record documentation
- Work effectively with CDI team members to accomplish departmental goals
- Learn/develop the skills necessary to perform Clinical Documentation review of clinical documentation
- Dependable, self directed and pleasant. Critical thinking, problem solving and deductive reasoning skills
- Able to effectively educate Physicians, coders and others on clinical documentation, coding and reimbursement opportunities.
- Critical Care Experience in the ED or ICU, or 5 years Med/Surg in-patient nursing experience
- Experienced computer user including word processing, spreadsheet, and database systems and graphic presentation programs
3
Skills For Risk Adjustment Clinical Documentation Specialist Resume
- Two (2) years of professional nursing experience in an emergency department, medical or surgical area of an acute hospital setting
- Experience in med-surgical or critical care nursing, practices case management and/or clinical chart auditing
- Typically, 6 years industry experience working in the Pharmaceutical, Biotechnology or other related industry is required
- Three (3) years of recent inpatient coding experience
- Proficient experience with MS Office applications including Word, Excel, and Outlook
- Certified Coding professional with 1-2 years CDS experience
- Dependable and self-directed with the ability to successfully multitask and manage confliciting priorities
4
Skills For Clinical Documentation Specialist International Md-days Resume
- Recent clinical experience in a hospital setting
- Nursing experience in an acute care facility
- Experience in medical record management and/or medical record auditing, preferably within the substance use treatment industry
- Strong understanding of healthcare reimbursement mechanisms
- Past experience maintaining business files in an organized manner
5
Skills For Clinical Documentation Specialist Clinical Documentation Improvement East Orlando Resume
- Clinical experience in an acute care setting
- Recent hospital nursing experience in MedSurg, Acute or Critical Care
- Acute Care Hospital experience
- Pediatric experience in Med/Surg, Critical Care, Emergency or PACU
- Entry Rate: $30.16 or more depending on experience
- Establish and maintain effective professional working relationships with those contacted in the course of work
- Skillfully and tactfully resolve complex requestor problems and complaints
6
Skills For Contingent Clinical Documentation Specialist Resume
- Five years RN experience in an acute Care setting
- Five years RN experience in an Accute Care setting
- Demonstrates knowledge of DRG’s, clinical documentation requirements, and referral policies and procedures
- Inpatient surgical experience
- Develops and/or poses compliant and effective written or verbal CDI physician queries, in compliance with organizational and AHIMA standards
- Demonstrates continuing expertise in data management and analysis. Able to interpret financial reports, audits, etc
- Revising, writing, reviewing and initiating new SOPs as needed
- Working knowledge of Medicare reimbursement and coding structures
- Working knowledge of Medicare reimbursement systems and coding structures desired, not required
7
Skills For Mkt Manager Clinical Documentation Specialist Resume
- Working knowledge of home health and CMS requirements for OASIS and Plan of Care for both clinical and billing needs
- Working knowledge of all areas of adult medicine
- Providing clinical support and education to Post Acute Clinical Providers
- Following –up with the physician responsible for the care of the patient, via the query process, for clarification of clinical significance
- Understanding of the coding classification systems ICD-9, ICD-10, CPT, HCPCS
- Performing initial case reviews and appropriate number of follow-up reviews based on program standards
8
Skills For Clinical Documentation Specialist Case Management Resume
- Using clinical insight and judgment of clinical findings to assess clinical documentation for improvement opportunities
- Position requires reaching, bending, stooping, and handling objects with hands and/or fingers, talking and/or hearing, and seeing
- Physical demands require standing, walking, sitting, lifting, carrying up to 25 lbs
- Critical thinking, problem solving, and deductive reasoning
- Frequent close eye work (computers, typing, reading, writing)
- Abstract for patient data fields, abstracting and coding techniques and statistical methods
9
Skills For Clinical Documentation Specialist Days Fountain Valley Resume
- Office of State Wide Hospital Planning and Development (OSHPD) reporting requirements
- Educates all members of the patient care team, including medical staff, on documentation guidelines on an ongoing basis. Orients new hires to CDMP processes
- Evaluates medical record documentation using knowledge about HIM Standards of coding
- Comfortable working in an environment with rapidly evolving needs, responsibilities, and expectations
- RN clinical or inpatient coding exp.in an acute care setting
10
Skills For Clinical Documentation Specialist, HIM DV Resume
- Ensures the accuracy and completeness of clinical information used for measuring and reporting physician and medical center outcomes
- As necessary, reviews clinical issues with coding staff to assign a working DRG
- Abiltiy to type correspondence, reports and other items as requested, ensuring that typing is accurate
- Position requires sitting for approximately 4-6 hours per day and walking for 2 hours per day
- Ensure optimal billing methods that meet with billing compliance standards (regulations)
- Is responsible for coordinating and delivering the orientation to EMR system for new clinicians in collaboration with other members of the education team
List of Typical Responsibilities For a Clinical Documentation Specialist Resume
1
Responsibilities For Senior Clinical Documentation Specialist Resume
- 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
- Outstanding communication, presentation, and organization skills
- Analyze moderately complex problems using structured problem solving skills, generating necessary data from appropriate sources
- Superior judgment, decision making and problem solving skills with the ability to assess issues and determine the best course of action
- Skilled and experienced at managing vendors and third parties
- Promotes evidence-based practice care and documentation of skilled care
- Current adult learning theory and practices, including effective group and individual training techniques
- Effective methods of using audiovisual equipment and other training aids or materials
2
Responsibilities For Lead Clinical Documentation Specialist Resume
- Author the first draft of SLRs, CER assessments, new CERs and scheduled CER updates for Terumo BCT products, according to business and research priorities
- Generate compliant and clinically valid clarifications to providers using Nuance CDI best practices for worksheets and clarifications
- Generates clarifications to ensure documented conditions in the medical record are clinically valid, present on admission, consistent, and not conflicting
- Remain organized using a daily work flow, but able to handle interruptions and high priority requests
- Three (3) years pervious acute hospital inpatient coding experience required
- Strong analytical thinking - able to analyze data & evaluate information to focus work efforts
- Recent clinical experience in a hospital setting
- Experience interfacing with customers or role in customer support
3
Responsibilities For Risk Adjustment Clinical Documentation Specialist Resume
- Critical Care/ICU experience is highly desirable
- Able to prioritize and multitask with multiple staff to assure deadlines are met
- Route POs, invoices, and vendor information in SAP, as well as recommend cost-effective improvement strategies
- Communicating cooperatively as needed with coding specialists
- Meeting with the lead physician advisors, as needed
- Analyzes a wide variety of operative, diagnostic, monitoring and life-sustaining medical procedures for abstracting and coding purposes
- Utilizes knowledge of CMS and regulatory environment to inform daily practice, including coding clinics and coding guidelines
- Groups-- regarding specific documentation matters as they relate to coding and reimbursement issues required for appropriate billing and reimbursement purposes
- The learning process as applied to both formal classroom instruction and in-house training methods
4
Responsibilities For Clinical Documentation Specialist International Md-days Resume
- Able to develop teaching tools or presentation material and enjoys teaching
- Conducts initial concurrent review and ongoing re-reviews for all selected admissions
- When scheduled, provides clinical documentation and billing compliance education which support Federal and State rules and regulations
- Seeks continuing education opportunities in order to stay current on CDI matters and/ or to maintain credentials
- Maryland Board of Nursing Licensure
5
Responsibilities For Clinical Documentation Specialist Clinical Documentation Improvement East Orlando Resume
- Assist with maintaining clinical trial files in electronic Trial Master File
- Attend cGMP training per department policy
- Complete SOP and on-the job training per department policy
- Compile audit findings and formulate communication that conveys medical necessary services were ordered and provided warranting claim payment
- Monitor and translate Vendor related upgrades and new modules for the agency. Advises and participates in decisions regarding adoption of new functionality
- Coordinates training for management team and field staff as needed for any EMR updates
- Assist with training contractor(s) on Clinical Evaluation Report development, as needed
- Advanced computer functions, data entry, knowledge of working in data base is required
6
Responsibilities For Contingent Clinical Documentation Specialist Resume
- Provides periodic formal and informal in-service updates to medical staff and other disciplines using both one-on-one and group forums
- Serves as a resource to Physicians / Case Managers and other key professional staff in matters relating to published DRG information
- Works with medical records, finance and physician groups to develop systems to facilitate complete documentation for data reporting purposes
- Responsible for the timely review and processing of Home Health OASIS discharge document
- Participates in management of RAC/PROBE/etc denial processing
- Keeps abreast of regulatory changes related to documentation, coding and communicate these changes to appropriate staff
- Reviews 8-10 cases/day and follows up on 85% of existing cases each day
- Clarifies for diagnoses using the 360 format
7
Responsibilities For Mkt Manager Clinical Documentation Specialist Resume
- Participates in revenue cycle meetings, providing data relative to reimbursement concerns
- Serves as an institutional subject matter expert and resource for interpretation and application of coding rules and regulations
- Master’s in Nursing or health care related field
- CCS (Certified Coding Specialist) credential
- RN and/or CCS Coding Certification required
- Certified Inpatient Coding Specialist (CCS) required within 12 months of hire
8
Responsibilities For Clinical Documentation Specialist Case Management Resume
- Medical services, and patient treatment interrelationships and sequences of a comprehensive teaching hospital
- English grammar, punctuation, spelling, and general English usage
- High level of computer proficiency and comfortable working in a totally electronic environment without paper
- Maintain a daily schedule that allows team interaction, ability to attend meetings, join calls, and provide client services during normal hours of operation
- Capable of extended periods of sitting
9
Responsibilities For Clinical Documentation Specialist Days Fountain Valley Resume
- Documents findings on the DRG worksheets
- Identifies key pathway or quality indicators, as appropriate
- 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
- 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
- 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
- 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
- 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
- Proactively solicits clarification from physicians to ensure key aspects of care have been appropriately recorded in the patient’s chart
10
Responsibilities For Clinical Documentation Specialist, HIM DV Resume
- 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
- Proactively solicits clarification from physicians to ensure points of clarification have been recorded in the patient’s chart
- Knowledge of ICD-10 CM/PCS and maintains full currency of Medicare and Medicaid regulations regarding clinical documentation and billing compliance for Part A and B services
- Reviews inpatient medical records both concurrently and retrospectively for identified payer populations as directed on admission and throughout hospitalization. Analyzes clinical status of patient, current treatment plan and past medical history and identifies potential gaps in physician documentation
- Works concurrently to ensure documentation of discharge diagnosis (es) 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. This includes but is not limited to: chart reviews, chart re-reviews, APR/DRG match, query compliance, and impact, etc
- In collaboration with physician/Nurse Practioner leadership, departments and team, assists with development and implementation of specific tools/education to support medical record physician / Nurse Practitioner documentation
- Participates in both formal and informal education sessions with physician, nurse practitioner, nursing, HIM and other clinical staff. Educates on the importance of documentation, necessary verbiage, and to provide a better understanding of what certain codes mean
- Acts as clinical liaison between HIM / coding staff and physician / nurse practitioners
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