Clinical documentation improvement specialist
- Clinical Documentation Improvement Specialist at Optum 360
- Coder Auditor / CDI at Prime Healthcare Management
- Branch manager / medical Division manager at SONY Middle East dealer
- Sales Manager at
3 months at this Job
- Bachelors - medicine & Surgery
Redding, CA 96001 Clinical Documentation Improvement Specialist, Supervisor: Andreea Trailescu
- Clinical Documentation Improvement Specialist, Supervisor at Shasta Regional Medical Center
- Assistant physician, Medical Scribe, Supervisor Hossam Amin, M.D at Ben Sinai Medical Center
- Supervisor at Ministry of Health Eltawfikia Health Care Unit
2 years at this Job
- - Certified Medical Scribe
- Bachelor of medicine and surgery M.B.Ch.B. - United States Medical License Exams
• Clinical Documentation Improvement Specialist is responsible for improving the overall quality and completeness of clinical documentation. Facilitates and obtains appropriate physician documentation for any clinical conditions or procedures to support the appropriate severity of illness, expected risks of mortality, and complexity of care of the patient.
- Clinical Documentation Improvement Specialist at Navigant/Cymetrix Healthcare Corporation
- Nurse Reviewer, HEDIS Temp/Seasonal Projects at Advantmed
- Float Nurse at Decatur Morgan Hospital
- Part-time student, medical at Billing and Coding
5 years, 1 month at this Job
- Certificate of completion - Licensed Practical Nursing
Agana, Guam, USA. TeAM, Inc./Standard Technology Inc./Healthcare Technologies Solutions, Inc. (U.S. DoD Contracts) Supervisor: Darla Lopez/Todd Perry/Sam Fye, (671) 344-9340, Hours Per Week: 40-48 Site Lead/Clinical Documentation Improvement Specialist (2017 - Present)
- Site Lead/Clinical Documentation Improvement Specialist at UNITED STATES NAVAL HOSPITAL
- Site Lead/Inpatient & Outpatient Provider Auditor/Trainer at
- Medical Records Coder at GUAM MEMORIAL HOSPITAL AUTHORITY
- Office Manager at
2 years at this Job
- Bachelor of Science in Health Information Management
- Associate of Science - Supervision and Management
- - Collegiate Nursing Coursework
Coder Auditor/ Performance Improvement Coordinator]
• Providing expert level review of inpatient clinical records admitted within 24-48 Hours.
• Generating Queries that require clarification for accurate ICD-10 code assignment to ensure that clinical documentation accurately reflects the severity of the condition and acuity of care provided.
• Managing reimbursement/HIM employees involved in clinical documentation and abstracting.
• Determination of cases for which CDI opportunities are derived
• Clarification of co-morbid and major co-morbid conditions required for coding and stratifying reimbursement
• Reviewing concurrent inpatient accounts to ensure completeness and accuracy of services provided to the patients.
• Assigning the MS-DRG and look for documentation improvement opportunities.
• Reviewing each case with the physician and providing tools to improve documentation.
• Accountable for active daily management of Discharged Not Final Billed (DNFB) work queues to assure targets are consistently met.
• Inpatient multispecialty coding; outpatient coding types which include onetime ancillary/series, emergency department, observation, wound care and day surgery.
• Ensuring the accurate and timely completion of all coding related activities.
• Ensuring coding and medical record documentation guidelines to assure compatibility and compliance with all regulatory, third party and SHC policies especially with the knowledge of ICD 10 Coding guidelines.
• Providing knowledge and technical support to expatriate coders for the establishment and maintenance of documentation standards and policies and procedures related to coding activities.
• Working with the Core Measure team to ensure quality improvement and proper data analysis. Core measure abstractions, monthly blood reviews, monthly restraints safety reviews, monthly mortality reviews, monthly coroner cases reviews, CABG abstractions and submission of CABG data to CORC, concurrent influenza and pneumococcal vaccine audit.
• Concurrent reviews, Inpatient CM Surveillance (STK, VTE, SEP), CDQM (Truven Health Analytics and Date reports).
• Inpatient and Out Patient Validation (Corporate audit/validation 100%) and Facility Audit/Validation random target selections.
- Clinical Documentation Improvement Specialist at Prime Healthcare Services
4 years, 5 months at this Job
Facilitate clinical documentation improvement through the identification of documentation issues impacting revenue, severity and quality.
- Clinical Documentation Improvement Specialist at Millcreek Community Hospital
- Inpatient Coder at Millcreek Community Hospital
- Health Information Management Manager at Millcreek Community Hospital
- Health Information Management Supervisor at Millcreek Community Hospital
4 years, 10 months at this Job
• Performs dual role of a manager of seven (7) Clinical Documentation Specialists and a hands on Clinical Documentation Specialist.
• Directly manages the Clinical Documentation Specialists including selection, performance evaluation, scheduling, and counseling of these team members.
• Provides orientation of newly hired Clinical Documentation Specialist including educational training on MS/AP DRG assignment, ICD 10-CM, PCS, coding clinics and coding guidelines.
• Conducts regular meetings with Clinical Documentation Specialists to discuss cases that require follow-up with medical and nursing staff, and provides instruction on documentation interventions, coding and reimbursement rules and regulations.
• Provides ongoing education to physicians, physician assistants, and nurse practitioners to improve overall documentation in the EHR.
• Serves as a clinical resource person for the clinical documentation staff including the coding team.
• Indirectly supervises the coders and coding trainees.
• Collaborates with physician leadership, coding team, case management, and health information systems team to implement changes in the current electronic health record that are reflective of current changes in ICD 10, coding guidelines, AHA, CMS policies and regulations.
• Collaborates with coding leadership to perform retrospective reviews/second reviews of post-discharge charts to identify potential documentation improvement.
• Collaborates with coding leadership in performing DRG validation.
• As a CDI, performs daily concurrent and follow up reviews to identify documentation gaps and query opportunities to maximize DRG. Covered various clinical areas including open heart surgery, trauma surgery, orthopedics, general surgery, OB-GYN, and general medicine.
• Confers with coding team and leadership to ensure accuracy of DRG assignment.
• Serves as a resource person to clinical staff to improve overall documentation that is accurate and is in compliance with regulatory guidelines.
- Manager, Clinical Documentation Improvement Specialist at Maimonides Medical Center
- Nurse Case Manager at Maimonides Medical Center
- Senior Critical Care RN at New York Methodist Hospital
- Critical Care RN at Bronx Lebanon Hospital
9 years, 7 months at this Job
- MS - Nursing Critical Care
- BS - Nursing
Albany, NY, August 2015- present Review inpatient medical records on a daily basis, concurrent with patient stay, to identify opportunities to clarify missing or incomplete documentation. Collaborate with providers, case managers, coders, and other healthcare team members to facilitate comprehensive health record documentation that reflects clinical treatment, decisions, diagnoses, and interventions. Utilize the hospital's designated clinical documentation system to conduct reviews of the health record and identify opportunities for clarification. Conduct follow-up of posted queries to ensure that queries have been answered and physician responses have been appropriately documented. Enhance expertise in query development, presentation, and standards Gather and analyze information pertinent to documentation findings and outcomes. Develop provider education strategies to promote complete and accurate clinical documentation and correct negative trends. Identify patterns, trends, variances, and opportunities to improve documentation review processes. Registered Nurse
- Clinical Documentation Improvement Specialist at St Peter's Hospital
- Registered Nurse at North Shore University Hospital
- Registered Nurse at Mercy Hospital of Philadelphia
- Pharmacy Technician at CVS Pharmacy
3 years, 5 months at this Job
- Master's - Nursing Informatics
- Bachelor's - Nursing
- Diploma - Nursing
- Bachelor's - Commerce
• Identifying "opportunities"/gaps in the clinical notes (inconsistent or conflicting information, unsupported diagnosis, and undiagnosed clinical indicators)
• Addressing these gaps by verbal, written, and electronic queries to Providers
• Support to CDIs at main site and all community hospitals
• Educating Providers and colleagues on clinical documentation on multiple fora
• Highlighting documented clinical evidence for DRG optimization
• Additional focus on shortening the revenue cycle, HAC, PSI, Case Mix index, observed to expected mortality ratio, general data appreciation and more
- Clinical Documentation Improvement Specialist at Baystate Medical Center
- at Till Incorporated
- Externship at Pacific Interpreters/Language Line Solutions
- Medical Interpreter at Pacific Interpreters/Language Line Solutions
1 year at this Job
- MBA - Healthcare Management
- Bachelor of Med - Bachelor of Surg. MBBS
DUTIES: Responsibilities include facilitating improvement in inpatient clinical documentation through concurrent review of the medical record for accurate physician documentation of diagnoses based on clinical evidence present in the chart.
- Nurse; Clinical Documentation Improvement Specialist at Registered
- Registered Nurse; Case Manager at Registered
- Registered Nurse; Case Manager at Registered
- Registered Nurse at Registered
1 year, 8 months at this Job
- A.D.N. - Nursing Program
- - Animal Science