Facilitated improvement in the overall quality and completeness of medical record documentation
through the query process along with formal and informal education.
• Impacted financial reimbursement through improved quality of clinical documentation. Reviewed medical records for identified payer populations (for example Medicare, Medicaid, Private Insurance payers) as directed on admission and throughout hospitalization.
• Worked with Physician Advisor to improve Physician response to queries.Documented reviews in Meditech system to ensure accurate reporting
- Clinical Documentation Improvement Specialist at Wyckoff Medical Center
- Clinical Documentation Improvement Specialist at St. Claire's Hospital
- Medical Assistant at Care Med
- Externship at Long Island Jewish Medical Center
1 year, 1 month at this Job
- Bachelors of Medicine - Bachelors of Surgery
I am currently working as a Clinical Documentation Specialist. I will take my certification when I reach my 2 year requirement.
- Clinical Documentation Improvement Specialist at Raleigh General Hospital
- Case Management Assistant Director at Raleigh General Hospital
- Case management/utilization review at Raleigh General Hospital
- Registered Nurse/Charge Nurse at Raleigh General Hospital
1 year, 3 months at this Job
- Bachelor's - Nursing
• Review of all Clinical documents and ensuring optimal standards.
• Liaising with billers to ensure proper billing.
• Assigning correct ICD 10 codes to diagnosis.
• Education of all clinical staff on proper clinical documentation.
- Clinical Documentation Improvement Specialist at WELIM AZINGE MD Inc
- Senior Medical Officer at MRS OIL
- Medical Officer at LAGOON HOSPITAL
- Medical Officer at SMITH MEDICAL HOSPITAL
2 years, 2 months at this Job
- Bachelor's - Medicine and Surgery
- Bachelor of Medicine and Surgery - Medicine and Surgery
Performed initial and follow-up medical record audits regarding physician documentation within 24-48 hours of patient admission to ensure the clinical documentation accurately reflects the patient's medical conditions. ◆ Collected medical data related to patient illness, complexity of care, severity of illness and risk of morality. Ensured proper documentation of co-existing diagnoses and secondary complications to accurately reflect the patient's status and care. ◆ Prepares training sessions to leadership, NYU residents and allied healthcare team members regarding clinical documentation compliance, updates on ICD-10 coding guidelines and the effect on quality of care, coding accuracy and hospital reimbursement. ◆ Monitors for opportunities to clarify clinical documentation and increase hospital resource allocation through the Veterans' Equitable Resource Allocation (VERA). Reported quantitative data and metrics of monthly record reviews on workload capture, cost determination, morbidity, mortality, and research and hospital reimbursement.
- Clinical Documentation Improvement Specialist at U.S. Department of Veterans Affairs-VA
- Contact Representative at Social Security Administration (SSA)
- Student Internship at Atlantic Institute of Oriental Medicine
- Supply Warehouse-Procurement and Supply Specialist at Lebanon Veteran Affairs Hospital Medical Center
3 years at this Job
- Bachelors of Health Science - Health Science
- My typical role is to create and/or champion an initial idea for performance improvement, and then persuade and guide the hospital's service to develop the principles and adopt the interventions needed. - Work with Director of HIM, Attending's, CDI staff, Coders and Nursing staff to provide and coordinate education related to compliance, coding and DRGs to properly support clinical documentation and identify opportunities for education. - Knowledge of all DRG and their structure, as well as, SOI, ROM, CCs and MCCs - Liaison between system management , CDI, coding leadership and physicians to create, implement and monitor of departmental policies and new changes according to new regulations. - Review inpatient medical records on a daily basis, concurrent with patient stay, to identify opportunities to clarify missing or incomplete documentation using the hospital’s designated clinical documentation system. - Facilitate improvement in the overall quality, completeness and accuracy of medical record documentation. - Knowledge of clinical documentation requirements per ACDIS, AHIMA and CMS g
- Clinical Documentation Improvement Specialist/liaison at Hackensack UMC at Pascack Valley Medical Center/Ardent
- Clinical Documentation Improvement Specialist/ Appeal Analyst at Mount Sinai Beth Israel
- Coordinator Manager at Bellevue Hospital
- Medical Chart Reviewer (Quality Management Department) at Lincoln Hospital
4 months at this Job
- General Medicine
o. Facilitates appropriate physician documentation to support accuracy of severity of illness, expected risk of mortality, complexity of care, HCC's and clinical validation through documentation review and physician education. o. Successfully meets metric standards for concurrent inpatient reviews by creating working DRG's on all payer types in a 124 bed facility and 120 bed facility sister facility which includes Tele, Med Surg, ICU, PCU, Ortho, and PCN with up to 30-35 reviews on new and re-reviewed accounts daily. o. Successfully meets CC and MCC capture rates. o. Assist with Outpatient medical coding along with medical coding of Inpatient accounts. o Ensures quality and compliant query practices with monthly query compliance audits. o Valued member of the Sepsis collaborative team, reviewing sepsis mortality cases and creating presentations with findings identifying opportunities for improvement. o Established Safety Coach, responsible for recommending and developing hospital protocols and changes throughout the facility and ancillary department's. While also exhibiting team checking, coaching and support for all members of the team regardless of department. Achieved Safety Coach of the month for my involvement in developing a more robust and detailed education regarding Braden Scale scoring for the nursing staff. o. Instrumental in identifying inaccuracies in I&D charges resulting in recapturing lost revenue and ensuring accuracy of coding and billing practices. o Accurately completes Quality Reviews on HAC and PC accounts, reporting all findings to Risk and Compliance. o Audits Inpatient and Outpatient documentation validating physician orders, notes, completeness, and compliance of charts required by CMS. o. Works closely with facility CFO on high dollar private pay accounts to ensure accuracy of cost and chart analysis. o Train new CDIS employees for the facility. o Responsible for reporting daily variance length of stay report and case mix index to CFO and heads of other ancillary departments. o Active contributor to the daily length of stay huddles which includes all department directors to ensure safe care during patient stay and discharge.
- Clinical Documentation Improvement Specialist at CHS-Bayfront Health
- NPR, Florida Medical Office Representative I at BayCare Medical Group
- Customer Service Representative at Staff Works LLC
4 years, 1 month at this Job
- Bachelors of Science in Nursing - Nursing
Responsible for improving overall quality and completeness of medical record documentation.
• Performed concurrent record reviews on all Medicare, Medicaid and other payor admissions and documented findings.
• Facilitated modifications to clinical documentation to accurately reflect patient severity of illness and risk of mortality through extensive verbal and written interaction with physicians, case management, nursing staff, other patient caregivers and health information management coding staff.
• Ensured the accuracy and completeness of clinical information used for measuring and reporting physician and hospital outcomes.
• Maintained accurate records of review activities to comply with departmental and regulatory agency guidelines
- Clinical Documentation Improvement Specialist at UASI
- Clinical Documentation Improvement Specialist at Medpartners
- Clinical Documentation Improvement Specialist at Harmony Health Solutions
- Clinical Documentation Improvement Specialist at Precyse Solutions
2 months at this Job
- - Nursing
Facilitates improvement in the overall quality, completeness and accuracy of medical record documentation. Obtains and promotes appropriate clinical documentation through extensive interaction with physicians, nursing staff, other patient caregivers and Health Information Management Department coding staff to ensure clinical documentation reflects the level of service rendered to patients is complete and accurate. Educates all members of patient care team on documentation guidelines, on an on-going basis.
- Clinical Documentation Improvement Specialist at Ballad Health
- RN Emergency Room at Mountain States Health Alliance
- Infusion Center RN/manager at Gastroenterology Associates of Northern Virginia
- Clinical Documentation Improvement Specialist at Ballad Health
8 months at this Job
- Associate Degree in Nursing - Nursing
- Certificate in practical nursing
♦ Perform reviews on concurrent medical records for overall quality and completeness of clinical documentation. ♦ Collaborates and queries physicians to improve clinical documentation for more accurate case mix. ♦ Education of physicians and medical staff regarding clinical documentation opportunities, coding, reimbursement issues, and regulation changes. ♦ CDI lead for Length of Stay Taskforce and Multidisciplinary Rounds spread throughout network.
- Clinical Documentation Improvement Specialist at Navigant Cymetrix-Seton Medical Center Austin
- RN CASE MANAGER-Paul Bass Clinic at SETON HEALTHCARE FAMILY
- DIRECTOR OF NURSING at AMERICAN SENIOR COMMUNITIES, Rosegate Village
- CLINICAL TRAINER at American Senior Communities
4 years, 7 months at this Job
- B.S. - Nursing
- Masters in Business Administration
Conduct concurrent and retrospective review of patient charts to identify opportunities for improvingthe quality of the medical record. Obtain appropriate physical documentation for any clinical condition or procedure to support theappropriate severity of illness and complexity of care of the patient. Educate physician and healthcare providers on the importance of complete and accurate clinicaldocumentation as it relates to patient. Assure documentation of discharge diagnosis and any co-morbidities are a complete reflection of thepatient's status and care. Review discharged patient's charts to ensure appropriate DRG assignment and any missedopportunities. Clinical documentation improvementsepcialist Reno, NV
- Clinical documentation improvement specialist at Prospect Medical Holding, Inc
- at Prime Health Care Services
2 years, 4 months at this Job
- Doctor of Medicine, MD - Medicine