Clinical Documentation Specialist

• Oct 2015 - Present

Facilitate clinical documentation of patient care which includes capturing of diagnoses that impact present on admission (POA), severity of illness (SOI), and risk of mortality (ROM) scores. Perform initial and follow-up reviews of inpatient records within hours of admission to evaluate the quality of the clinical documentation. Initiate physician interaction for documentation at point-of-care. Facilitate clinical documentation of patient care which includes capturing of diagnoses that impact present on admission (POA), severity of illness (SOI), and risk of mortality (ROM) scores. Perform initial and follow-up reviews of inpatient records within hours of admission to evaluate the quality of the clinical documentation. Initiate physician interaction for documentation at point-of-care.

Integrity and Compliance Specialist

• Sep 2014 - Oct 2015

Clinical Documentation Specialist

• Mar 2012 - May 2014

Clinical Data Analyst

• Aug 2007 - Mar 2012

Abstracted clinical data from inpatient and outpatient medical records for Core Measures and entered into databases for CMS and TJC. Performed monthly Core Measure reports for department liaisons within the organization. Abstracted clinical data from inpatient and outpatient medical records for Core Measures and entered into databases for CMS and TJC. Performed monthly Core Measure reports for department liaisons within the organization.