Clinical Documentation Improvement Resume Samples

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C Legros

Cara

Legros

905 Allison Shoals

Los Angeles

+1 (555) 367 3089

905 Allison Shoals

Los Angeles

Phone

p +1 (555) 367 3089

Experience Experience

New York, NY

Clinical Documentation Improvement

New York, NY

Walker-Jacobson

New York, NY

Clinical Documentation Improvement

Review inpatient medical records for identified payor populations (i.e., Medicare, Medicaid, Managed Care etc.) as directed on admission and throughout hospitalization, analyzing clinical status of patient, current treatment plan and past medical history and identifies potential gaps in physician documentation
Ensure that clinical documentation reflects the level of service rendered to patients in complete, accurate and compliant with the regulations of the Center for Medicare and Medicaid Services
Perform initial charts reviews and assign working DRG within 24 hours of admission, on the working days
Assist in the development of compliant diagnosis/DRG specific queries to aid physicians with proper and precise documentation
Maintain up to date working DRG and has clear strategies to effectuate improved quality of clinical documentation for all the select cases
Regularly participate in scheduled case management meetings and actively exchange information pertaining to clinical documentation, plan of care affecting coding and reimbursement
Take responsibility in addressing medical necessity issues through concurrent review process, initiating compliance with CORE measures before discharge and assisting in follow-up on queries and clarifications to physicians concurrently and retrospectively

Dallas, TX

Director of the Clinical Documentation Improvement

Dallas, TX

Murray-Fahey

Dallas, TX

Director of the Clinical Documentation Improvement

The individual will promote accurate concurrent documentation from all disciplines (physicians, case managers, nurses, dietitians, wound care specialists etc.) to capture best practice documentation for specific diagnoses. He/She will also conduct regular retrospective reviews for coding accuracy, missed opportunities, consistency of documentation and education of CDS and coding staffs
The individual should meet or exceed expected time lines on performance level related to personnel, budgeting and reporting responsibilities
This role serves as a translator between Finance and the Clinical Staff, and plays a vital role in improving accurate quality reporting for both provider and the facility
The individual will monitor performance of staff under him/her using departmental KPIs
The position provides strategic planning and concentrated daily oversight of the Clinical Documentation Improvement Program
The individual will provide ongoing education to all members of the medical staff
The individual will be responsible for development and execution of CDI program for assigned Prospect Medical Holding Hospitals

present

Chicago, IL

Director Clinical Documentation Improvement Altamonte Springs

Chicago, IL

Hilll LLC

present

Chicago, IL

Director Clinical Documentation Improvement Altamonte Springs

present

Responsible for recruiting and providing support, guidance and mentorship to Clinical
Oversees expense including resource utilization for supplies and staff
Establishes and maintains communication with Financial Planning and Revenue Cycle Business Analytics team
Rehires within 12 months are not eligible
Contribute to the design and development of a clinical documentation improvement program in coordination with hospital and division leadership
Collaborate with peers regarding department budget and operational plan development to maintain fiduciary responsibility and achieve greater financial performance
Up-to-date knowledge of ICD-10 mandate and the impact of code set transition (e.g., potential impact on data quality for prospective payments, utilization, and reimbursement)

Education Education

Bachelor’s Degree in Nursing

University of California, Berkeley

Bachelor’s Degree in Nursing

Skills Skills

Effective oral and written communication skills, with the ability to articulate complex information in understandable terms to all levels of staff
Customer-focused attitude and ability to work proactively and efficiently with appropriate urgency
Strong organization skills
Effective computer skills, particularly Microsoft Office Outlook, Word, Excel
Ability to work in a matrix-management environment to achieve organizational goals
Ability to establish and manage complex and effective relationships
Excellent analytical and problem-solving skills
Up-to-date knowledge of ICD-10 mandate and the impact of code set transition (e.g., potential impact on data quality for prospective payments, utilization, and reimbursement)
At least seven to ten years’ acute hospital clinical experience
Ten plus years of experience in a clinical documentation improvement program

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Director of Clinical Documentation Improvement Resume Examples & Samples

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

Clinical Documentation Improvement Manager Resume Examples & Samples

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

Clinical Documentation Improvement Principal Consultant Resume Examples & Samples

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

Clinical Documentation Improvement Senior Consultant Resume Examples & Samples

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

Senior Director Clinical Documentation Improvement Resume Examples & Samples

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

Clinical Documentation Improvement Manager Resume Examples & Samples

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

Manager, Clinical Documentation Improvement Resume Examples & Samples

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

Clinical Documentation Improvement Product Consultant Resume Examples & Samples

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

Division Director of Clinical Documentation Improvement Resume Examples & Samples

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

Clinical Documentation Improvement Director Resume Examples & Samples

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

Director of Clinical Documentation Improvement Resume Examples & Samples

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

Director of the Clinical Documentation Improvement Resume Examples & Samples

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

Clinical Documentation Improvement & Utilization Management Specialist Resume Examples & Samples

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

Clinical Documentation Improvement Team Leader Resume Examples & Samples

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

Clinical Documentation Improvement Consultant Resume Examples & Samples

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

Clinical Documentation Improvement Director Days Resume Examples & Samples

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

Manager Clinical Documentation Improvement Resume Examples & Samples

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

Manager, Clinical Documentation Improvement Resume Examples & Samples

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

Clinical Documentation Improvement Liaison Resume Examples & Samples

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

Manager Clinical Documentation Improvement Resume Examples & Samples

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

Clinical Documentation Improvement Division Leader Resume Examples & Samples

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

Clinical Documentation Improvement Resume Examples & Samples

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

Clinical Documentation Improvement Resume Examples & Samples

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

Director Clinical Documentation Improvement Altamonte Springs Resume Examples & Samples

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