Clinical Documentation Resume Samples

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A Cummings

Aletha

Cummings

67411 Fisher Rapid

Detroit

+1 (555) 675 0746

67411 Fisher Rapid

Detroit

Phone

p +1 (555) 675 0746

Experience Experience

Dallas, TX

Clinical Documentation Liaison

Dallas, TX

Welch-Steuber

Dallas, TX

Clinical Documentation Liaison

Collaborates with physician, physician extender, nurse, case manager/utilization reviewer and Medical Records coder to identify principal diagnosis options, secondary diagnoses and procedures, to assign working DRGs for at least 80-85% of identified populations. Conducts initial and extended-stay concurrent reviews on all selected admissions, and documents findings, denoting all key information utilized in the tracking process
Runs reports as requested by Nurse Manager, CDS’s or Administration
Maintains positive open communication with physicians, inter-disciplinary care team members and department manager
Provides concurrent review of the clinical documentation in the medical record
Develops and conducts ongoing CDMP education for new staff, including new clinical documentation specialist, coders, physicians, nursing and allied health professionals
Performs concurrent review of the clinical documentation in the medical record
Queries the medical staff and other caregivers as necessary via written/verbal communication to obtain accurate and complete physician documentation that supports the severity of patient illness and risk of mortality

Philadelphia, PA

Clinical Documentation Quality Coordinator

Philadelphia, PA

Parker, Feest and Sawayn

Philadelphia, PA

Clinical Documentation Quality Coordinator

Generate MSHS CDI policies and guidelines in accordance with AHIMA Practice Briefs, Official Coding Guidelines, ACDIS standards and Coding Clinic
Collaborate with the CDI Manager in the analysis of CDIS reports and other statistical reviews
Provide feedback to HIM management staff and CDI leadership regarding opportunities for documentation improvement and participates with the planning and development of educational programs directed towards improving documentation
Analyze reports and identifies trends and statistical significance in coding opportunities as well as CDI opportunities that will assist in the organizational process of documentation improvement
Educate and mentor new employees through the on-boarding process. Trains CDI staff on initial CDI review and query process and provide on-going education related to new topics in CDI, coding and reimbursement
Assist with the analysis of PSIs and HACs to ensure that the coding assignment was properly assigned based upon review of the medical documentation and application of coding guidelines
Participates in education programs

present

Phoenix, AZ

Clinical Documentation Integrity Specialist

Phoenix, AZ

Dickinson-Schinner

present

Phoenix, AZ

Clinical Documentation Integrity Specialist

present

Plans, builds and executes programs, educational strategies, tools and other program elements to achieve operational objectives
Leads projects through planning, development, implementation and monitoring
Facilitates issue identification and resolution
Collaborates with documentation team and Institute to manage project portfolio that supports HVI priorities with impact on outcomes, reputation and reimbursement
Compiles data, performs analysis and advises the documentation team on interpretation and/or validation of data; recommends solutions to meet objectives
Defines data reporting tools, business intelligence dashboards and data fields
Provides education, training and support to Providers (Attending Physicians, Hospitalists, Fellows, Residents, Physician Assistants and Nurse Practitioners.) on clinical documentation, coding guidelines and workflows

Education Education

Bachelor’s Degree in Health Information Management

Indiana University

Bachelor’s Degree in Health Information Management

Skills Skills

Excellent time management skills and the ability to manage multiple priorities effectively
Able to audit for accuracy in a timely manner and follow up on all cases quickly, especially those with clarifications
Ability to demonstrate critical thinking, problem solving and excellent interpersonal skills
Knowledge of pathophysiology and disease process
Excellent organizational, analytical, and writing skills
Dependable and self-directed
Ability to pass written clinical competency exam
Able to communicate effectively and appropriately with individuals at all levels of the organization
Meets Health System's Core Values and Caring Standards including interpersonal communication and professional conduct expectations
Ensure physician documentation contains adequate indicators to support the coding of diagnoses representative of each patient

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Director of Clinical Documentation Resume Examples & Samples

5+ years management knows
Strong grasp of Medicare & Medicaid guidelines
Previous experience in Clinical Documentation
Relevant experience in any clinical discipline such as Acute Care nursing, Utilization Management, Quality Management or as a hospital-based Physician Assistant or physician extender will be considered
Current NYS RN or PA licensure coupled with CCDS, CDIP or CCS certification

Clinical Documentation Consultant Resume Examples & Samples

Acts independently in performing clinical review of medical charts to accurately identify presence of medical conditions not diagnosed or captured in electronic health record
Demonstrates excellent medical and coding knowledge and applies this knowledge in making appropriate clinical judgment based on review of electronic helath records
Demonstrates a high level of quality work and appropriate productivity, and is measured by these quality and productivity standards
Acts as subject matter expert in several medical conditions and uses Adult Learning Theory to train and coach other team members in these areas
Analyzes and makes recommendations for the data mining work performed by the local facilities, including data mining prompt stop analyses
Competently utilizes computers and computer software, including word processing, spreadsheet, and presentation software to complete job duties
Adheres to the hospital standards to promote a cooperative work environment by utilizing communication skills, interpersonal relationships, and team building
Establishes effective working relationships with the local and regional staff/teams/leadership and is able to provide ongoing feedback and support constructively and sensitively in order to improve data mining performance
Reviews clinical issues with medical coding staff and with physicians to identify those diagnoses that impact severity of illness indicators for each patient. Serves as an expert resource in reviewing all medical records in support of consistent documentation for all payer types (i.e. CMS, Medicare-Advantage, etc) to ensure complete and accurate diagnosis capture and coding
Conducts data and root cause analysis, provides feedback and shares findings on the analysis to leaders, local and regional management and medical team. Queries medical staff for accurate clear documentation in the patients' medical records. Monitor and track verbal and written queries and produce reports as required
Minimum three (3) years of clinical experience (i.e. inpatient, clinical documentation, discharge planning, case management.)
Minimum eight (8) years of inpatient coding experience, including MS-DRG, APR-DRG or similar methodology
Current Procedural Terminology (CPT), Healthcare Common Procedural Coding (HCPCS), MS-DRG, HCC strongly preferred

Clinical Documentation Spec Resume Examples & Samples

Education: RN license in state of Michigan, BSN highly desirable
Experience: 3 years recent RN experience required, preferably in a critical care area
Licensure: RN
Skills & Abilities: Exemplary organizational and communication skills. Ability to build relationships, negotiate process and outcomes and influence behaviors. Must be computer literate with the ability to interpret statistical reports. Possess the ability and willingness to accept autonomy with responsibility, and commitment to collaborative practice

Clinical Documentation Spec Resume Examples & Samples

Analyzes inpatient records for status of the patient, current treatment plan and past medical history to identify potential gaps in physician documentation
Based on the review the Clinical Documentation specialists may query the physician verbally and/ or in writing to assure the appropriate documentation is documented in the body of the medical record, to capture the patient’s severity of illness
Able to communicate with attending physicians and residents to validate observations
Able to work closely with the HIM coding staff to assure documentation of discharge diagnosis and any co-existing, co-morbidities that are a complete reflection of the patient’s clinical status and care
Minimum of 2 years hospital experience required
Recent coding experience,
Utilization Review or Case Management Experience preferred
Bachelor’s degree in healthcare related field preferred
RN or RHIA preferred
Must possess advanced communication and interpersonal skills with all levels of internal and external customers
Must demonstrate excellent written/verbal communication, critical thinking, creative problem solving, and conflict management skills
Must be proficient in organization and planning
Must possess strong computer skills including the use of spreadsheets, presentation programs, word processing, and Internet searching
Must demonstrate working knowledge of quality improvement theory and practice
Must have working knowledge of DRGs and medical necessity criteria
Knowledgeable of Federal, State, and other payers’ regulations, requirements, and criteria

Clinical Documentation Spec Resume Examples & Samples

Ability to work from home
Facilitate appropriate clinical documentation of inpatient medical records including the capture of diagnoses and procedures that impact present on admission (POA), severity of illness (SOI), risk of mortality (ROM) scores, hospital reimbursement and quality of patient care
An Associate’s or Bachelor’s Degree in Health Information Technology and registration with the American Health Information Management Association as a RHIT or RHIA or bachelor’s degree as an RN or an advanced degree as a NP, PA, or MD
Analytical: Can recognize key clinical indicators in patient records to identify opportunities to query clinicians for documentation of diagnoses or procedures needed to obtain a complete quality medical record
Experience as a Clinical Documentation Specialist is desired

Clinical Documentation Integrity Coordinator Resume Examples & Samples

Demonstrates excellent written and verbal communication skills, critical thinking, decision making and interpersonal skills. Proactively escalates risks and issues to CDI Leadership to ensure timely and effective resolution
Assists the CDI Manager with the development and analysis of reports to identify key metrics to monitor CDI program success and identify potential for process improvement and educational opportunities for CDI staff, Coding staff, and Physicians
Assists the CDI Manager with the screening of new CDI applicants

Allscripts Clinical Documentation Consultant Resume Examples & Samples

Works with management and end users to identify, analyze and prioritize documentation needs and requirements
Analyzes complex clinical operations and structure processes to facilitate decision making regarding clinical documentation in SCM
Participates in rounding/shadowing with a variety of clinical end users to gather requirements from and perform gap analysis
Document requirements from users
Develops clinical documentation using the configuration tools within Allscripts SCM
Ensures all build is completed within established time frames
Maintains complete and detailed build documentation
Troubleshoot any found/reported issues and communicate with clinical documentation supervisor
2+ years of experience within a health care environment
Ability to interact with stakeholders throughout the organization (business owners, HIM professionals, Informatics professionals, etc.) is required
System design, implementation, integration and testing experience
Excellent communication, documentation and presentation skills, required
Proficient use of MS Office (Outlook, Word, Excel, Power Point, Visio, SharePoint)

System Clinical Documentation Information Specialist Resume Examples & Samples

Licensed Registered Nurse, RHIA, RHIT, CCS, LPN or combination thereof preferred
Minimum of five years’ experience in an acute adult in-patient clinical role for RNs and LPNs with demonstrated critical thinking skills or a minimum of two years’ experience with inpatient coding for coders, process improvement in an acute care facility preferred or equivalent experience
Coding skills with experience in ICD-9-CM, knowledge of CMS Inpatient Prospective Payment System, and working knowledge of AHA Coding Clinic
Current licensure as a registered nurse in state of practice (if applicable)
Certified Clinical Documentation Improvement Specialist (CCDS) or Certified Documentation Improvement CDI Practioner highly preferred
Proven communication skills in dealing with multidisciplinary clinical and operations teams including physicians
Current working knowledge of one or more of the following: Medical /Surgical Nursing, Critical Care, Care and Case Management (Resource Utilization), Surgical Services, Accreditation and Regulatory Compliance, Core Measures and Public Reporting of Hospital Quality Data

Clinical Documentation DRG Specialist Resume Examples & Samples

Building and Maintaining Strategic Working Relationships – develops collaborative relationships to facilitate the accomplishment of work goals. Possesses excellent interpersonal skills in building, negotiating and maintaining crucial relationships
Communication – communicates clearly, proactively and concisely with all key stakeholders
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
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
Customer orientation – establishes and maintains long-term customer relationships and ensures that the customer perspective is the driving force behind all value-added business activities
Negotiate and influence others – facilitates agreement in order to influence positive outcomes
Policies & Procedures – articulate knowledge and understanding of organizational polices, procedures and systems
Minimum 5 years recent case management/utilization/quality review and/or other related clinical experience in an acute care facility required
Knowledge base of ICD-9-CM coding and understanding of Diagnostic Related Groups (DRGs) strongly preferred

Clinical Documentation Operations, Director Resume Examples & Samples

Drive the embedding and implementation of Pharma TMF and associated systems across Pharma R&D by working directly with Study Teams as they use the Pharma TMF system to ensure inspection readiness throughout the study lifecycle
Be accountable for the business process and associated written standards and training strategy for TMF specialists
Represent Pharma in Pharma/Vaccines/CHC cross-business unit discussions to ensure consistency in TMF working practices and alignment on continuous improvement
Drive the embedding and implementation of eTMF and associated systems across Pharma R&D
Partner with Clinical Development Quality Assurance to create and operationalise a TMF Inspection Readiness support team that guides study teams preparing for regulatory inspections
Work with the business to improve our understanding of the challenges and associated solutions to ensure excellence in inspection readiness on a day-to-day basis
Contribute to TMF strategies with external collaborators such as Transcelerate and others in the document management arena
Line manage, coach and develop team members as required in support of the above deliverables

Clinical Documentation Integrity Coordinator Resume Examples & Samples

Obtain appropriate clinical documentation through extensive interaction with physicians, nursing staff, other patient care givers, and 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
Facilitate appropriate clinical documentation to ensure that level of services and acuity of accurately reflected in the medical record
Educate internal staff on clinical documentation guidelines and conduct follow up reviews of clinical documentation to ensure points clarified with the physician have been recorded in the patient’s record. Reviews clinical issues with the coding staff to assign a working DRG
Generate accurate reports for the client upon the close of each phase of an engagement
Knowledge of CDI strategies
Associate’s Degree in a relevant field or combination of equivalent education and experience
RN, CCDS or CDIP

Clinical Documentation Integrity Specialist Resume Examples & Samples

Plans, builds and executes programs, educational strategies, tools and other program elements to achieve operational objectives
Leads projects through planning, development, implementation and monitoring
Facilitates issue identification and resolution
Collaborates with documentation team and Institute to manage project portfolio that supports HVI priorities with impact on outcomes, reputation and reimbursement
Drives agenda items and reports on progress as required for team meeting
Compiles data, performs analysis and advises the documentation team on interpretation and/or validation of data; recommends solutions to meet objectives
Defines data reporting tools, business intelligence dashboards and data fields
Provides education, training and support to Providers (Attending Physicians, Hospitalists, Fellows, Residents, Physician Assistants and Nurse Practitioners.) on clinical documentation, coding guidelines and workflows
Creates and provides a scorecard to each Provider that measures the impact of the implemented documentation improvement strategies
Audits and analyzes Provider clinical documentation to identify compliance and opportunities for improvement
Develops and manages effective relationships with all stakeholders including high-level physician constituency and institute administrators
Develops and delivers presentations regarding projects, data and workflow analysis, issues and recommendation
Clinically experienced and must be well-versed in clinical operations required
Physician education and CPT, ICD9/10 Coding and DRG assignment experience strongly preferred
EMR savvy; Epic experience preferred
Demonstrates strong written and verbal communication skills
Effective in presenting to leadership
Demonstrates ability in creative problem-solving, negotiations, group processes, and delivery of job related content
Must be self-directed with demonstrated ability to work independently yet establish cooperative relationships with colleagues
Demonstrates strong analytical skills; experience in data analytics preferred
Proficiency in Microsoft Office products required.

Clinical Documentation Lead Resume Examples & Samples

Provides leadership in organizing, coordinating, and leading the CDI team
Serves as the Subject Matter Expert (SME) for any topics related to provider documentation
Conducts meetings and education for the CDI team and other facility staff as needed
Acts as a liaison through effective and professional communications between and with Facility, Division and/or Corporate staff
Represents the CDI team at Facility, Division, or Corporate meetings
Reviews medical records and identifies potential gaps in clinical documentation for specified facilities, patient types and payer populations, as directed on admission and throughout the hospitalization
Assigns working DRG based upon identification and selection of principal diagnosis, complications or co-morbid conditions and/or valid OR procedures, including capture of POA indicators
Ensures documented conditions, clarifications, and coded diagnoses are clinically supported
Queries physicians as necessary within established timelines via approved query forms for conflicting, imprecise, incomplete, illegible, or inconsistent documentation by requesting and obtaining additional documentation within the health record when appropriate. Interacts with Physicians to complete/resolve queries prior to patient discharge
Compiles, creates and delivers education to physicians and other key healthcare providers. Mentors new CDI staff during orientation and through ongoing education
Demonstrates knowledge of Official Coding Guidelines and the DRG Classification System to insure compliance with such regulations as they relate to the CDI function
Associate’s Degree in nursing required
Bachelor’s Degree or Master’s Degree in nursing preferred
Minimum of three (3) to five (5) years of nursing experience required,experience in case management, critical care or emergency services preferred
One (1) to two (2) years clinical documentation experience in acute care preferred
One (1) year of supervisor experience preferred

Clinical Documentation Liaison Resume Examples & Samples

Promotes an environment that minimizes potential and actual injury to the internal/external customer
Provides concurrent review of the clinical documentation in the medical record
Queries the medical staff and other caregivers as necessary via written/verbal communication to obtain accurate and complete physician documentation that supports the severity of patient illness and risk of mortality
Performs a thorough chart review to identify that co-morbidities/complications are documented appropriately
Completes the DRG worksheet and reviews documentation of the medical record every 2 days
Demonstrates creativity and enthusiasm while pursuing the goals of the department and the organization
Maintains the ability to be flexible, and prioritizes daily responsibilities
Maintains relationship with HIM coders to assure an accurate and complete medical record
Collaborates with physician, physician extender, nurse, case manager/utilization reviewer and Medical Records coder to identify principal diagnosis options, secondary diagnoses and procedures, to assign working DRGs for at least 80-85% of identified populations. Conducts initial and extended-stay concurrent reviews on all selected admissions, and documents findings, denoting all key information utilized in the tracking process
Identifies need to clarify documentation in records, and utilizes strong communication skills with physician, physician extender, case manager, utilization reviewer, nurse or other healthcare professionals, utilizing appropriate tools to capture needed documentation. Works collaboratively the healthcare team to facilitate documentation within the medical record that supports patient’s severity of illness and risk of mortality
Utilizes monitoring tools to track the progress of the DRG Assurance program, through interpretation of DRG tracking reports (DocMS), monitoring reports and data. Shares findings with identified staff DRG Assurance meetings. Able to identify areas of focus through report analysis
Serves as a resource to physicians and administration regarding issues related to the appropriateness of inpatient DRG assignment
Assists in the development of APR/DRG/query response physician reports. Maintains complete confidentiality of patient information, in addition to hospital and individual physician practice pattern data
Provides information and in-services as necessary to physicians and ancillary staff
Performs other duties as may be required/requested

Clinical Documentation Improvemen Manager Resume Examples & Samples

Knowledge of Medicare Part A and familiar with Medicare Part B
PC/Systems literate including the Internet and MS office skills
Management of multiple priorities – effective time management skills
Capacity to work independently in a virtual office setting or at facility setting if required to travel for assignment
Recognize opportunities for documentation improvement
Formulate clinically, compliant credible queries
Overall knowledge and ability to drive operational metrics

Epic Clinical Documentation Applications Analyst Resume Examples & Samples

Bachelor’s Degree or equivalent blend of education and experience
4 or more years of industry build experience with Epic Clinical Documentation in an information services and/or acute care Pharmacy department environment
Skilled in information collection and troubleshooting root cause of application failures
Knowledgeable of application architecture
Knowledgeable of database configurations, queries and elements
Epic Clinical Documentation Certification

Clinical Documentation Speclst Resume Examples & Samples

In partnership with appropriate personnel, develops and implements standardized, organization-wide reporting guidelines and documentation requirements and develops and implements training and educational programs for physicians, coders, case managers and/or other affected personnel
Serves as a resource for department managers, staff, physicians, and administration to obtain information or clarification on accurate and ethical reporting and documentation standards, guidelines, and regulatory requirements
Initiates corrective action to ensure resolution of problem areas identified during internal or external auditing
Provides feedback and focused educational programs on the results of auditing and monitoring activities to affected staff and physicians
Ensures the appropriate dissemination and communication of all reimbursement regulation, policy, and guideline changes to affected personnel
Reports CDI Scorecard and Query Log information to HIM Manager and the Vice President of Medical Affairs on a monthly basis
Maintains established hospital and departmental policies and procedures, objectives, performance improvement program, safety, environmental and infection control standards. Maintains confidentiality and security levels to protect medical/legal patient care documentation

Clinical Documentation Liaison Resume Examples & Samples

Facilitates appropriate clinical documentation to ensure that the level of services and acuity are accurately reflected in the medical record to the extent that the physician concurs
Maintains knowledge of documentation requirements in accordance with AHA Coding Clinic
Performs admission and continued stay reviews using CDMP documentation guidelines to improve the overall quality and completeness of clinical documentation, and to ensure ordered procedures meet medical necessity guidelines
Assists in processing the discharges by updating the Severity/Complexity of CDMP Worksheets to reflect any changes in status, procedures/treatments, and conferring with physicians to clarify principal diagnosis
Educates medical and internal staff on clinical documentation guidelines
Conducts follow-up reviews of clinical documentation at least every 48 hours or as indicated to ensure that points of clarification with the physician have been recorded in the patient’s chart
Reviews clinical issues with the coding staff regarding DRG assignment
Ensure documentation is technically accurate on a concurrent basis that facilitates the most appropriate code assignment for PDx, PPx, Comorbid Conditions and complications
Confers with coding professionals concurrently to ensure appropriate DRG and completeness of supporting documentation
When contacted by coders, regarding concerns / disagreements about DRG or documentation issues, CDS will review the medical records and if approved, follow-up with physicians, as appropriate, in a timely manner
Reviews the chart with the Coding Coordinator and/or manager, if unable to reach agreement with the coding specialist
Participates in patient care conferences / case conferences to identify needs for clinical documentation
Develops and conducts ongoing CDMP education for new staff, including new clinical documentation specialist, coders, physicians, nursing and allied health professionals
Tracks responses to CDMP and trends / tracks compliance
Demonstrates clinical knowledge skills / abilities for the patient population served
Maintains records, documenting chart documentation compliance
Maintains positive open communication with physicians, inter-disciplinary care team members and department manager
Possesses knowledge of HCFA documentation guidelines and works with physician to achieve the appropriate documentation
Maintains knowledge of current guidelines through use of the Docu-Prompters and Coding Clinics
Maintains knowledge of physician office coding with the use of appropriate Docu-Prompters
Demonstrates knowledgeable working expertise in the use of Microsoft Word, Power Point and Excel programs
Possesses knowledge of local, state and federal entitlement programs
Runs reports as requested by Nurse Manager, CDS’s or Administration
Assists in Medical Staff Presentations and updates as needed
Demonstrates clinical knowledge of the RAC and ADR programs
Performs other tasks assigned, which are within the employee’s capabilities

Clinical Documentation Spec Resume Examples & Samples

Education:B.S. degree in a clinical discipline (nursing, respiratory therapy, etc.) or equivalent experience is required
Experience:Minimum of 5 years experience adult inpatient medical/surgical or critical care
Licensure/Certification/Registration:Current TN licensure in clinical discipline
Skills:Analytic skills necessary to clinically assess medical records and communicate clinical detail. Demonstrated excellence with written and verbal communication skills. Computer skills in word processing and spreadsheet utilization. Excellent prioritization and organizational skills. Must possess sight/hearing senses or use prosthetics that enable these senses to function adequately so that the requirements of the position can be fully met. Occasional reaching and stooping to file in file cabinets. Dexterity to review charts and input data into the computer. Occasional lifting up to 20-25 lbs. to carry or convey portable computer. Ability to maintain sensitivity and confidentiality associated with hospitalization

Clinical Documentation DRG Specialist Resume Examples & Samples

Works closely with CDS and HSC coding staff to assure all coding is complete, accurate, and consistent and results in appropriate reimbursement and data integrity
Reconciles CDI reviews with HSC coding summaries
Initiates CDI coding referrals to the HSC coding staff for second level reviews
Tracks identified trends based on internal coding reviews and provide coding education to CDS
Reviews HSC monthly query trending reports to identify missed CDI query opportunities
Coding Certification (RHIT, RHIA, CCS, or CCA)
Minimum 3 years of acute care hospital inpatient coding experience
Clinical knowledge and understanding of pathology/physiology
Working knowledge of Medicare reimbursement system

Epic Clinical Documentation Analyst Resume Examples & Samples

Proficiency in more than two computer environments or platforms
Ability to work with a computer terminal for extended periods of time
Ability to handle multiple projects
Excellent technical aptitude
Excellent training skills
Flexible and effective in a team environment

Clinical Documentation Quality Coordinator Resume Examples & Samples

Perform reviews of inpatient records to (a) evaluate documentation to assign the principal diagnosis, pertinent secondary diagnoses, and procedures for accurate and optimal DRG assignment; (b) evaluate appropriateness of documentation to support quality standards including PSIs, HACs ; (c) identify missed secondary diagnoses and procedures; (d) query clinicians to achieve improved clinical documentation and accurate coding for optimal allowable reimbursement; (e) perform DRG reconciliation and inform HIM of any recommended coding changes
Analyze reports and identifies trends and statistical significance in coding opportunities as well as CDI opportunities that will assist in the organizational process of documentation improvement
Work closely with the CDI, HIM and Quality team to provide feedback ensuring coding consistency and accuracy meeting the requirements of: ICD-10 CM/PCS, UHDDS and sequencing guidelines, Federal and State regulations, American Hospital Association Coding Guidelines and Coding Clinic
Educate and mentor new employees through the on-boarding process. Trains CDI staff on initial CDI review and query process and provide on-going education related to new topics in CDI, coding and reimbursement
Provide feedback to HIM management staff and CDI leadership regarding opportunities for documentation improvement and participates with the planning and development of educational programs directed towards improving documentation
Develop and maintains compliant query templates as needed due to annual changes in the Inpatient Prospective Payment System (IPPS) and AHA Official Coding Guidelines and Coding Clinics
Generate MSHS CDI policies and guidelines in accordance with AHIMA Practice Briefs, Official Coding Guidelines, ACDIS standards and Coding Clinic
Collaborate with the CDI Manager in the analysis of CDIS reports and other statistical reviews
Assist with the analysis of PSIs and HACs to ensure that the coding assignment was properly assigned based upon review of the medical documentation and application of coding guidelines
Maintain confidentiality of information acquired pertaining to patients, physicians, associates, and visitors to the Hospital. Discusses patient and hospital information only among appropriate personnel in private places
Assumes responsibility for performance of job duties in the safest possible manner, to assure personal safety and that of co-workers, and to report all preventable hazards and unsafe practices immediately to management
Responsible for remaining current with the latest healthcare technology and coding advice through reading available coding literature, attendance of seminars and in-services, internet research and other educational resources for inpatient and outpatient reimbursement and coding
Participates in education programs

Manager, HIM Clinical Documentation Resume Examples & Samples

Bachelor’s degree in health information management or related field (or completion within six (6) months)
Skills: Acute care inpatient coding and CDI proficiency; Strong clinical knowledge; Knowledge of revenue cycle, reimbursement systems and regulatory/legal/compliance; Effective communication and presentation skills
Years of Experience: 3-5 years of management experience
License: N/A
Certification: RHIA/RHIT or RN
Education: BSN
Skills: Proficiency with spreadsheets, databases, coding/CDI, reimbursement and EHR Systems
Years of Experience: 5-8 years of management experience
Certification: CCS or CDIP

Clinical Documentation Spec Resume Examples & Samples

Licensed Registered Nurse (R.N.) in the State of Illinois
Bachelors of Science Degree in Nursing required
Five years’ experience in medical/ surgical, critical care, intensive care or emergency care preferred
Demonstration of advanced clinical expertise required
Must possess and consistently demonstrate: Strong interpersonal, communication, conflict management, diplomacy and negotiation skills
Proven leadership to affect positive clinical quality outcomes
Analytical skills necessary to independently collect analyze and interpret clinical data
Basic computer skills and willingness to learn computer applications relative to this position

Clinical Documentation Analyst Resume Examples & Samples

Requires three (3) years recent coding experience
RHIA, RHIT, CCS preferred
ICD-10 knowledge preferred
Clinical Documentation Improvement experience preferred
Thorough understanding of medical terminology, anatomy and physiology is required
Strong critical thinking skills needed to identify documentation and coding opportunities, based on diagnoses, symptoms and findings in the medical record
Strong oral and written communication, organizational, and interpersonal skills required

Clinical & Documentation Review Consultant Resume Examples & Samples

Quality Audits & Reviews: Coordinates monitors & audits all lines of hospital business for coding & clinical documentation integrity, to include: all outpatient, inpatient, HOV, ED & Ambulatory surgery cases
Monitors the accuracy & quality of coding & CDI assignments, Present on Admission (POA) indicators & conducts internal coding audits
Acts as the Reg’l coding contact person for the HIM Dept to support Edu & coding requirements
Develops & presents reports of audit results to Reg’l & facility staff & Sr Mgmt
Helps set the direction for coding & compliance Edu & focused projects related to the electronic medical record
Provide oversight & training for "Coding Compliance Software" to the coding staff
Run audit selection lists & reports as well as providing Edu, feedback & guidance based upon data mining activities, processes & clinical documentation requirements
Monitoring & Reporting: Monitors & coordinates coding & clinical documentation integrity audit activities
Develops reports of audit findings as required for operational, compliance & risk reporting
Conducts data & root cause analysis, provides feedback & shares findings to revenue cycle leaders & others as appropriate
Prepares statistical & annual reports as requested by Revenue Cycle leadership, state or Fed agencies or any others
Develops, maintains, & communicates up-to-date & accurate coding & clinical documentation guidelines & policies to all impacted parties
Coding & Clinical Documentation Edu & Training: Supports the Reg’l coding & clinical documentation audit, Edu, & training needs of the region
Conducts exit conferences on audit findings for the coding & CDI staff & Mgmt
Provides Edu & training on coding & documentation issues identified during audits & reviews
Collaborates w/the coding & CDI Mgmt staff in the developing programs which provide alignment w/Edu for internal customers to enhance clinical documentation & comply w/coding guidelines
Audit Coordination: Coordinates w/the coding & CDI Mgmt in planning & performing coding & documentation reviews for effective & timely completion of work
Collaborate w/the Revenue Cycle Business Risk Mgmt & other compliance & risk Mgmt units in identifying risk areas in coding & clinical documentation based on audit findings
Functions as a liaison for other Depts regarding coding & CDI audit questions & issues
Minimum five (5) years of acute care, inpatient, outpatient, DRGs, HCCs and APCs coding required
Minimum two (2) years of acute care, inpatient, outpatient, DRGs, HCCs and APCs auditing required
Minimum one (1) year of experience using electronic health records (EHR)
Bachelor's degree in health information management, business administration, healthcare administration or other related field
AHIMA Certified ICD-10 trainer preferred
CCDS credential preferred
CDIP credential preferred

Sahs Clinical Documentation Spec A Resume Examples & Samples

Current state Registered Nurse license is required, BSN preferred; RHIT, RHIA, or CCDS certification a plus
3 to 5 years varied hospital clinical experience required. Critical care or strong medical surgical background preferred
Understand and support compliant documentation strategies
Knowledge of pathophysiology and disease process
Knowledge of regulatory environment essential; knowledge of Medicare Part A and Part B is preferred
Excellent organizational, analytical, and writing skills
Ability to demonstrate critical thinking, problem solving and excellent interpersonal skills
Excellent time management skills and the ability to manage multiple priorities effectively
Dependable and self-directed
Ability to pass written clinical competency exam
Intermediate computer skills – familiarity with Windows based software programs
Meets Health System's Core Values and Caring Standards including interpersonal communication and professional conduct expectations
Ability to quickly learn and develop the skills necessary to perform the CDS role, including ability to accurately input relevant data into 3M 360 Encompass and Cerner PowerChart (special purpose software)
Ensure physician documentation contains adequate indicators to support the coding of diagnoses representative of each patient
Able to audit for accuracy in a timely manner and follow up on all cases quickly, especially those with clarifications
Formulates credible and compliant clarifications to improve clinical documentation of principle diagnosis, co-morbidities, evidence of indicators representing conditions present on admission (POA), and quality core measures
Facilitates modifications to clinical documentation of the medical record through extensive interaction with physicians, nurses, and ancillary staff
Develops and implement plans of education of physicians, nursing, and ancillary staff on documentation improvement
Reviews inpatient medical records for all payer populations on admissions and throughout hospitalization
Analyzes clinical information to identify areas within the chart for potential gaps in physician documentation
Able to communicate effectively and appropriately with individuals at all levels of the organization
Actively participate in cross functional Task Force meetings
Works collaboratively with the coding staff to assure documentation of discharge diagnoses and co-morbidities are a complete reflection of the patient's clinical status and care. Able to effectively communicate with HIM staff and resolve discrepancies
Responsible for completing all annual regulatory compliance education, as well as CDS-specific assigned education

Temp-clinical Documentation Associate Resume Examples & Samples

Manage access and organization of the controlled clinical document storage on-site at Regeneron, including ensuring the defined file structure is maintained
Maintain file QC schedule and perform periodic inventories of study/project TMFs to ensure completeness
Effectively communicate and drive document management compliance and quality issues to the clinical study teams and management, and offer potential solutions
Perform vendor TMF review and site visits, as applicable
Develop or assist in the development of standards for document workflow, organization and maintenance in the Clinical File Room
Function as subject matter expert on local and international GCPs related to TMF
Assist in developing, assessing, and providing training for TMF-related SOPs, working practices, and forms, as needed, in order to ensure adequate compliance
Assist in the development and implementation plan for an electronic TMF, including standards and governance
Provide status updates and information to management on a regular basis
Good interpersonal skills with an ability to work in a team environment and independently
Must be flexible and able to handle a face paced environment
Experience supporting quality/regulatory audits
Knowledge of eTMF systems (Nextdoc or Documentum preferred)
Understanding of the DIA TMF reference model preferred
Proficient in Microsoft Office software applications