North Highlands CA 95660
Looking for work within the company in the position of Clinical Documentation Improvement Specialist. Experienced with behind the scenes managerial duties as well as hands-on work in the industry.
Summary of Qualifications:
- Huge experience in conducting medical review and data analysis
- Sound knowledge of cared delivery documentation systems and medical record documents
- Extensive knowledge of disease processes and clinical medicine
- In-depth knowledge of CMS rules and regulations
- Proficient in 3M encoder, acute care abstracting, reporting applications and MS Office suite
- Familiarity with ICD-9, DRG system, HCPCS, MS-DRGS, data analysis and reporting
- Strong clinical assessment and coding skills
- Excellent communication and organizational skills
- Superior time management and analytical skills
Clinical Documentation Improvement Specialist, May 2006 – Present
HCA Healthcare, Pilot Grove, MO
- Prepared, maintained and updated clinical documentation ensuring completeness and accuracy of services provided to the patient.
- Collected and documented data related to patient illness, intensity of services and risk of mortality.
- Ensured proper documentation of discharge diagnoses and co-existing complications to completely reflect the patient’s clinical status and care.
- Developed and implemented plans for both formal and informal education of physician, nursing, and other clinical staff.
- Identified strategies for changing work process to facilitate complete, accurate clinical documentation.
- Ensured adherence to established productivity targets for record review.
Clinical Documentation Improvement Specialist, March 2003 – April 2006
Adirondack Medical Center, Pilot Grove, MO
- Monitored and recorded information on National Hospital Quality Measures (NHQM) inpatients.
- Trained nurses and physicians on NHQM standards.
- Acted as inter-departmental NHQM liaison.
- Coordinated the development, maintained and monitored data quality.
- Analyzed NHQM compliance provided regular progress reports to Core Measure Team.
- Maintained current competence in all aspects of NHQM.
Bachelor’s Degree in Healthcare, William Jewell College, Liberty, MO