Foreign Medical Graduate working as a Clinical documentation specialist, Medical coding, reviewing retrospective and concurrent cases for proper DRG assignment, health information Management, clinical data quality, clinical documentation improvement, acute utilization review, Medical coding-ICD 10, inpatient-acute care setting, ICU, medical and surgical(both same day surgery and inpatient surgery), medical and surgical terminologies
- Clinical Documentation Specialist II at Paradise Valley Hospital
- Shadowing Doctor at Garvey Healthy Family Medical Clinic
- Shadowing Doctor at Golden Pacific Nephrology Medical Clinic
- Shadowing Doctor at Good-faith Family Medical Group
2 years, 8 months at this Job
- Master’s degree in Nutritional Science, anticipated graduation in 2016 - Nutritional Science
- Bachelor's - Medicine
Responsibilities included improving the overall quality and completeness of clinical documentation; I accomplished this task by facilitating modifications to clinical documentation through extensive concurrent review of charts and interactions with physicians, nursing staff, and other caregivers. This position required working collaboratively with and supporting the medical coding team in their efforts to appropriately assign diagnostic codes. This position also entailed that the documentation specialist team educate members of the patient care team on an ongoing basis of the importance of their documentation in capturing clinical severity and care rendered, along with improving patients outcomes. As part of the documentation team I rotated assigned areas to include the Intensive care units, medical and surgical units, orthopedic and women care, all of which required an in depth knowledge of the specialty area and the ability to communicate effectively with physicians and staff of those areas.
- Clinical Documentation specialist at Phoebe Putney Health System
- Charge nurse on the adult and geriatric behavioral health unit at XPERIENCE
- Registered Nurse at XPERIENCE
- RN Clinical Documentation Specialist at XPERIENCE
2 years, 10 months at this Job
- Bachelor of Nursing - Nursing
- Associate - Nursing
Review provider documentation for clarity and consistency for application of a
DRG, as well as query for DRG, SOI and ROM improvement
• Act as a CDI Liaison to the contracted hospitalist group
• Reviews patient records in Critical Care, Telemetry, Trauma Orthopedics and Neurology floors
• Oriented two new RN CDI's to the role of CDI as well as, precepted two experienced RN CDI's to the facility.
• Query Response Rate: 99%, Personal Agreement Rate: 80%, Team Query Response Rate: 98%, Team Agreement Rate: 75 %
• Completed provider (Physician, PA & NP) education in the form of tip sheet Power Point presentations and New Physician Orientation
• Oriented new staff members to the role of Clinical Documentation Improvement Specialist and to the organization
• Maintain mutual respect and professional dialogue with coders in regards to specialization of each other's roles
- Clinical Documentation Specialist at UW Valley Medical Center
- Clinical Documentation Improvement Specialist at HonorHealth
- ICU Registered Nurse at HonorHealth
- Registered Nurse at HonorHealth
2 years, 2 months at this Job
- Master of Science - Nursing
- Bachelor of Science - Nursing
Reviewed clinical documentation for charge capture and quality improvement. Strategic planning and analysis for enhanced revenue. Educated staff on documentation deficiencies. Lead Specialist interim as needed for Supervisor.
- RN Clinical Documentation Specialist at Rush Copley Medical Center
- RN Emergency at Express Care Department, Rush Copley Medical Center
- RN at PACU, Rush Copley Medical Center
- RN Intermediate Care Area at Rush Copley Medical Center
9 years, 1 month at this Job
- Associates of Applied Science - Nursing
- Bachelor of Science - Biology
care hospitals, home health, hospice and long term acute care hospitals. Proficient in State, JCAHO and Medicare guidelines. Interdisciplinary collaboration with strategic planning and project management. Effective measurements of reimbursement, regulations and query opportunities. Leadership and management skills. LifeCare Hospital Of Plano February 2015 to current Plano, TX Clinical Documentation Specialist
- Clinical Documentation Specialist at LifeCare Hospital Of Plano
- at LifeCare Hospital Of Plano
- Registered Nurse- House at LifeCare Hospital Fort Worth
- Director of Business Development at Dependable Home Health/Sterling Home Healthcare
4 years, 1 month at this Job
•Review inpatient medical records for identified payer populations on admission and throughout hospitalization.
•Analyze clinical information to identify areas within the chart for potential gaps in physician documentation.
•Formulate credible clinical documentation clarifications to improve clinical documentation of principal diagnosis, co-morbidities, present on admission and quality core measures, patient safety indicators.
- CLINICAL DOCUMENTATION SPECIALIST at Conifer Health Solutions
- RN Case Manager at CHI St. Luke’s Health
- REGISTERED NURSE at BSN
- CLINICAL DOCUMENTATION SPECIALIST RN at BSN
2 years, 2 months at this Job
- Bachelors of Science - Nursing
Facilitates improvement in the overall quality, completeness and accuracy of medical record documentation. Obtains appropriate clinical documentation through extensive interaction with physicians, nursing and other patient care staff and Health Information Management coding staff to ensure that clinical documentation reflects the level of service rendered to patients is complete and accurate. Educates all members of the patient care team on documentation guidelines on an ongoing basis.
- RN Clinical Documentation Specialist at Park Nicollet Methodist Hospital
- RN Surgery Center at
- RN, Medical/Surgical Float Pool at Park Nicollet Methodist Hospital
- RN- Urology/Oncology at Surgery Center
2 years, 6 months at this Job
- Bachelor of Science in Nursing - Nursing
- Associate of Applied Science - Nursing
- Diploma - Nursing
- High School Diploma
Responsible for implementing a Clinical Documentation Improvement program at Harrington Hospital using clinical knowledge and experience, to closely collaborate with physicians, HIM, Case Management, Quality Department and IT Department to ensure that patient records accurately document the status, complexity and intensity of patient conditions and care.
- CERTIFIED CLINICAL DOCUMENTATION SPECIALIST at HARRINGTON HOSPITAL
- QUALITY AND PATIENT SAFETY COORDINATOR at HARRINGTON HOSPITAL
- Charge Nurse at BAYSTATE MEDICAL CENTER
- House person in charge and Customer satisfaction team member at GENESIS HEALTHCARE, HERITAGE HALL TRANSITIONAL CARE UNIT
2 years, 5 months at this Job
- Associate in Science of Nursing - Nursing
Under the guideline and policy set by the organization, pediatric clinical documentation review conducts to improve the documentation quality. Attending daily rounding with the attendings, fellows, residents, NPs and other care teams to work collaboratory for the quality of documentation to captures the condition more accurately and more specifically translating into appropriate ICD 10 code. Dedicated CDI member of CVICU, med and surgical floors to assist the team for the documentation improvement. Fluent system use in Cerner and Clinitegrity, a CDI module by JATA. as well as 3M. weekly CDI improvement meetings with the team, collaboration work with the coders, and learning the new ideas and share the ideas in pediatric CDI for the organization.
- Clinical Documentation Specialist at Children's Hospital of Orange County
- CDI Specialist at St. Francis Hospital ( Conifer health contractor)
- Clinical Documentation Improvement Specialist at Kaiser Permanente
- Clinical Documentation Specialist at Fountain Valley Regional Medical Center
1 year at this Job
- - International Medical Graduate Program
- certification - Hand Surgery and Neurosurgery
- Certification - elective completion
- BS - Biology
• Review and develop information for processes and diagnosis based on comprehensive knowledge of medical terminology, anatomy & physiology, disease processes, treatment modalities, diagnostic tests, medications, procedures as well as the principles and practices of health services.
• Accurately reflect and report the patient's severity of illness equating to intensity of service
• Responsible for facilitating improved overall quality, education, and completeness and accuracy of medical record documentation as well as promoting appropriate clinical documentation through extensive interaction with physicians, other patient caregivers, HIM coding staff and other associated staff to ensure clinical documentation and services rendered to patients are complete and accurate for appropriate workload capture and resource allocations
• Verify appropriate ICD-10/CPT codes are assigned to each case
• Initiate compliant physician queries when documentation is confusing, ambiguous or missing and follows up with MD to seek immediate response to query
• Ensure the query verbiage is in no way leading or suggestive in tone and is supported by the documentation in the record to include clinical indications and treatment provided
• Perform follow up on incomplete physician queries to obtain an answer.
• Analyze complete clinical documentation from a compliance, coding and/or reimbursement perspective including rationale for the initiation, discontinuation and/or adjustment of treatment modalities utilized in the care of the patient.
• Communicate directly with providers when needed.
• Review final documentation for accuracy and obtain finalization from medical professionals
• Develop and maintain professional working relationships with Medical Director, facilities and all providers within the IPA.
• Prepare for and present when assigned, case activity at meetings. Ensure follow up activities are completed, including but not limited to obtaining medical records and diagnostic tests results etc.
• Document clearly and appropriately all case related activity.
• Assist in the development and implementation of case management, utilization management and quality management policies and procedures. Attend department meetings as needed.
- Clinical Documentation Specialist at Advantage Plus Medical Center
- Clinical Laboratory Scientist (Generalist) at Luxor General Hospital
- General Practitioner doctor at Family Health Center El Pyadia
3 years, 11 months at this Job
- Bachelor Degree of Medicine and Surgery - MBBCh