Clinical Documentation Improvement Specialist Resume

Samantha Gray

North Highlands CA 95660

(916) 987-6543

[email protected]

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Job Objective

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

Work Experience:

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