Clinical Documentation Specialist 3

• Nov 2020 - Present

Clinical Documentation Specialist

• Aug 2013 - May 2020

- Concurrent review of inpatient acute care medical record documentation at 515 bed acute care hospital - Work face-to-face with doctors to improve their medical record documentation to fully reflect severity of illness, risk of mortality, medical necessity, and care provided - Focus on quality initiatives including Hospital Value Based Purchasing, Hospital Acquired Conditions, Patient Safety Indicators, and Hospital Readmission Reduction Program - Generate compliant physician queries - Interact with physicians to maximize response rate - Educate physicians on documentation requirements - Reconcile my coding with HIM department coders' coding to assure appropriate DRG assignment - Train new CDI Specialist hires - Interview CDI Specialist applicants - Member of Hospital Acquired Condition Committee - Member of Sepsis Performance Improvement Council Show less

Compliance Auditor, Clinical Documentation Audit Operations

• 2006 - 2012

- Worked face-to-face with doctors to improve their clinical documentation in HCC, Risk Adjustment environment - Reviewed medical record for physician query opportunities - Adhered to compliant query practice guidelines - Trained doctors for the initial HealthConnect EHR go-live as well as subsequent revisions and updates - Trained doctors on meeting CMS’ EHR Meaningful Use objectives - Worked face-to-face with doctors to improve their clinical documentation in HCC, Risk Adjustment environment - Reviewed medical record for physician query opportunities - Adhered to compliant query practice guidelines - Trained doctors for the initial HealthConnect EHR go-live as well as subsequent revisions and updates - Trained doctors on meeting CMS’ EHR Meaningful Use objectives

Coder

• Jan 2004 - Feb 2006

As a contract employee through an employment agency, I coded diagnoses and procedures using QuadraMed EHR. As a contract employee through an employment agency, I coded diagnoses and procedures using QuadraMed EHR.