Clinical Documentation Specialist Worked collaboratively with healthcare team to facilitate clinical documentation that accurately reflected quality of care, severity of illness, risk of mortality, and/or other quality indicators to support correct coding, reimbursement and quality initiatives. Children's Hospital of Alabama, 1600 7th Avenue South, Birmingham, AL 35233, January 3, 2017 to August 3, 2018. Utilization Management
- Clinical Documentation Specialist at Children's Hospital of Alabama
- Substance Abuse Counselor and Care Coordinator (Contract) at UAB Beacon Addiction Treatment Center
- Nurse Review to determine whether all aspects at Children's Hospital of Alabama
- Registered Nurse II at Children's Behavioral Health
1 year, 7 months at this Job
- Master of Arts in Education - Agency Counseling
- Bachelor of Science in Nursing - Nursing
The Clinical Director directs, coordinates, and has twenty-four hour accountability for the nursing services within a specified division of the hospital. She/he evaluates employee work performance providing personnel counseling and disciplinary action in cooperation with the Head Nurse and the CNO. The Clinical Director's responsibility includes development and maintenance of an ongoing quality monitoring improvement program. The Clinical Director communicates and collaborates with other department for problems identification and resolution. ◦ Tidelands Health Georgetown, South Carolina Clinical Documentation Specialist - Outcomes Measurement Department
- Clinical Documentation Specialist at Tidelands Waccamaw Community Hospital
- Clinical Director at Tidelands Waccamaw Community Hospital
- Education Specialist-RN at Tidelands Waccamaw Community Hospital
- Registered Nurse at Tidelands Waccamaw Community Hospital
8 years at this Job
- Masters in Business Administration - Healthcare
- Master's Degree - nursing
- Bachelor of Science - Nursing
of Albany - October 9, 2017-present 35 Colvin Avenue Albany, NY 12206 518-489-2681 Clinical Documentation Specialist/OASIS reviewer Review clinical documentation and ensure OASIS documentation accuracy. Review for accuracy of 485 orders. Resource for clinicians. Review for care plan appropriateness. Assure all orders on referral are implemented in plan of care. Medication review for accuracy.
- Clinical Documentation Specialist/OASIS reviewer at Visiting Nurse Association
- Utilization Mangement RN at Ellis Medicine
- RN Case Manager II at Athem Blue Cross Blue Shield
- Patient Care Coordinator at Center for Disability Services
1 year, 3 months at this Job
- AAS - Nursing
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, 6 months at this Job
- Master’s degree in Nutritional Science, anticipated graduation in 2016 - Nutritional Science
- B. S - medical
for Baylor University Medical Center
• Code diagnoses and procedures using ICD10CM for Inpatient DRG's cases for Trauma Level I and surgical cases such as; Cardiac, Vascular, Respiratory, Orthopedics, Pediatrics, NICU, OBGYN, & Long Length of Stays. Professionally commutate electronically with CDI Specialist, Auditors
• & coding Managers to resolve coding changes and computer issues maintained an accuracy rate of 95% or better.
• Shared new ICD10 coding knowledge when found with all fellow contractors, CDI Specialist, Auditors and Coding Managers.
• Inpatient diagnoses as required. Identify nonpayment conditions (HAC) and report as required. Correct disposition as required.
• Query physicians for clinical documentation specifics for quality documentation and correct reimbursement.
• Assist the CDI team with audits for chart deficiencies concurrently
• Query physicians for clinical documentation specifics. Produce reports that health providers can analyze to determine problems or areas of improvement.
• Communicating with health-care staff members specially physicians to explain their findings (Query)
- Clinical documentation specialist at Addison Group
- Concurrent and Retro clinical documentation improvement specialist and coding auditor at Prime Healthcare Services
- Clinical Documentation Improvement specialist and coding Auditor at Landmark Hospital RI
- Rotating internship in teaching university hospital at Khyber Medical University (PAKISTAN)
3 years, 3 months at this Job
- Bachelor - Medicine and Surgery
• Document clinical details of patients' conditions, diagnoses, and progress
• Ensure all relevant information pertaining of patient care is documented
• Document CAT scans, EKGS, and blood sample results
• Assist patients in submitting form for insurance
• Participate in inter-departmental training
• Review medical records and attest supporting documents
• Answer queries of patients and medical staff
• Gather, compile, and modify clinical documentation
- Clinical Documentation Specialist at Ibrahim bin Hamad ObaidAllah hospital
- Clinical Documentation Specialist at Kuwait Medical Center
4 years at this Job
- Master degree in Psychiatry - Psychiatry
- Bachelor's degree in medicine and general surgery - medicine and general surgery
Concurrently reviews and analyzes patients electronic medical records to assess documentation of principal and secondary
● Reviews and identifies potential opportunities to improve clinical documentation.
● Communicates with physicians, medical coders and others to improve the electronic medical record on various patients.
● Develops and presents education for physicians based on analysis and identification of clinical information in order to allow physicians to accurately and completely document on patient's medical records in order to allow for appropriate reimbursement according to CMS guidelines.
- Clinical Documentation Specialist at Texas Health Presbyterian Dallas
- Charge Nurse/Staff Nurse- Orthopedics/ Med at Surg Parkland Health and Hospital System
1 year, 9 months at this Job
- Bachelors of Science in Nursing - Nursing
- Associate of Applied Science - Nursing
• Collaborate with providers and other relevant healthcare team members to improve the quality of clinical documentation which accurately reflect the clinical treatments, decision and diagnosis for a given patient.
• Provide detailed expert review of inpatient clinical records by identifying any data which needs clarification in order to assign correct codes which will reflect correct DRGs, SOI, ROM among other factors needed for hospital reimbursement.
• Query providers when needed for further documentation clarification.
• Perform regular rounding with providers and all related healthcare team members to provide working DRGs and educate them about CDI.
• Have proficient knowledge and expertise in using software programs such as EPIC, 3M, Records 1, and Microsoft Office.
- Clinical Documentation Specialist at St. Joseph's Medical Center
- nurse practitioner, and physicians' assistants at St. Luke's Behavioral Health Center
- at Scottsdale Healthcare/Honor Health
- Medical Student at Hospital Angel Leano
6 months at this Job
- Doctor of Medicine - Medicine
- Bachelor in Science - Biological Sciences
• Responsible for all new provider CDI orientation including the development of a CDI physician orientation Power Point presentation.
• Work in collaboration with the CDI team to generate $1.88 M of revenue in the first year of the program ending January 2018.
• Concurrently review all inpatient medical records during the patient's hospitalization for appropriate and necessary Medical Staff clinical documentation.
• Promote daily communication with clinicians and physicians to ensure timely and accurate documentation to answer questions and provide training and education as needed.
• Query physicians daily for documentation opportunities obtained through review of the concurrent medical record and follow up for timely response from the physician.
• Responsible for collaborating with the CDI team to develop all provider education based on identified trends in documentation. Worked with the denials management team to formulate denial responses for retrospective denials
• Utilize the "Claro CDR2" Documentation Improvement software, Optum CAC and Meditech for CDS metrics, daily chart reviews and query formulation.
- Clinical Documentation Specialist at Exeter Hospital
- Clinical Documentation Specialist at Lakes Regional General Hospital
- Clinical Documentation Specialist at MetroWest Medical Center
- Sole Owner & Operator at The Walk In Closet
1 year, 6 months at this Job
- M.S. - Community Health Administration
- B.S. - Healthcare Administration
- A.S. - Nursing
Responsible for concurrent review of inpatient medical records in order to identify opportunities for improving the quality of physician documentation. Facilitates modifications to clinical documentation through concurrent interaction with physicians (verbally and electronically) and other members of the health care team. The goal is to achieve a complete medical record in order to support complete, accurate and timely coding.
- Clinical Documentation Specialist at Memorial Hermann
- Clinical Operations Manager at DaVita-VillageHealth
- CDU RN at Halifax Health
- Program Director at Restorix Health
1 year, 2 months at this Job
- AAS - Nursing