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Clinical Documentation Specialist Resume Samples
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0-5 years of experience
- Generated positive financial impact by my activities of over 2 Mil in 5 years.
- Increased accuracy of documentation resulting in a yearly increase in the Medicare blended rate.
- Increased the reimbursement on 25% of the charts reviewed, facilitating accurate MD documentation resulting in a DRG (final diagnosis) change.
- Review patient medical records to ensure accuracy of physician documentation as compared to the Medicare approved verbiage.
- Increase the accuracy of documentation and capture co-morbid conditions to more correctly reflect the mortality index of the facility.
- Instituted and implemented a WIKI to improve timely communication between staff on multiple units and serve as an information repository.
0-5 years of experience
Promoted appropriate clinical documentation through interaction with physicians, nursing staff, and HIM staff.
- 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, Blue Cross Blue Shield) as directed on admission and throughout hospitalization.
- Worked with Physician Advisor to improve Physician response to queries.
- Documented reviews in EPIC system to ensure accurate reporting.
6-10 years of experience
Ensures that quality indicators of severity of illness and risk of mortality are accurately reflected per documentation in the medical record
- Collaborates with staff, coders and physicians to identify and reflect the quality and acuity of administered care
- Responsible for accuracy of concurrent inpatient coding process and DRG assignment
- Successfully completed 30hr course-maintains Cerfication in ICD-10-CMS/PCS Hospital coding-“Certified to Code”
0-5 years of experience
After receiving a promotion to RAC Compliance Coordinator, responsibilities were kept as Clinical Documentation Specialist as time allowed.
- Reviewed and coded inpatient charts for purpose of querying physicians concurrently and IDOC for clarification of documentation of diagnoses, POA.
- A goal was to have accurate diagnoses reflect the severity of the patient’s condition, which helped to provide appropriate reimbursement.
- Completed training through J.A. Thomas and Associates, and maintained continuing education seminars.
- Documented and tracked in JATA computer software, 3M coding software, Cerner, MIDAS.
- Wrote coding appeal letters.
- Co-managed Clinical Documentation Department after manager left.
- RAC lead-until promoted to RAC Coordinator, presented RAC updates during RAC Committee and Revenue Cycle.
- Explained to physicians, residents and Nurse Practitioners about the importance of accurate documentation of diagnoses. Presented to physician groups.
- Presented Power Point presentations to senior leadership regarding coding changes and documentation challenges.
- Alerted risk management if Hospital Acquired Conditions were identified.
0-5 years of experience
Facilitated improvement in the overall quality, completeness, and accuracy of medical record documentation by performing prospective chart audits
- Extensive interaction with physicians to ensure the clinical documentation reflected the severity of illness and level of services rendered to patients
- Provided ongoing education of physicians and coding staff
- Analyzed aggregated data to identify patterns and areas of focus for documentation and coding improvement initiatives/education
- Participated in redetermination, reconsideration, and appeals process upon requests, related to recovery audits (RAC) and DRG validation
6-10 years of experience
Increased hospital’s case mix index equal to $1.4M in bottom line reimbursement in my first year
- Developed a communication tool between the coders, DRG validator and clinical staff to promote learning and maximize reimbursement
- Trained 2 brand new RN-CDI’s
- Participate on hospital teams: Utilization Review, CME, Core Measures and Leadership Council
- Suggested a hospital wide recycling program which came to fruition with a $7K yearly hospital savings in trash collection
6-10 years of experience
Developed new program for Compliant Documentation Improvement program (CDMP) at PHP in relation to THR’s organizational strategy, vision and initiatives
- Planned CDMP rollout, established timeline, and developed policies and procedure for new department
- Solved IT issues and ordered appropriate tools needed for the Clinical Documentation Specialists
- Proficient in Healthcare Coding utilizing tools such as 3M and JATA software
- Supervised two Clinical Documentation Improvement departments, Texas Health Allen and Texas Health Plano
0-5 years of experience
Helped to build first CDI program at the facility
- Performed concurrent/retrospective reviews of medical records, established a working MS-DRG, evaluated SOI/ROM, supported core measures and other quality reporting measures
- Worked with the CHW Midas team to develop and pilot parts of the CDI module and reports
- Partnered with the Registered Dietitians to identify at-risk patients for nutritional deficiencies and skin breakdown
- Presented monthly pressure ulcer data to the hospital president at HAPU Committee meeting
- Volunteered at the monthly Wound Care Committee meetings to discuss needed nursing documentation of wounds, skin breakdown, and POA indicators
0-5 years of experience
Conduct clinical reviews of outpatient office visit records to evaluate the clinical documentation for services provided.
- Facilitate ongoing achievement of the clinic’s goals.
- Consistently meet established productivity targets for record review and also successful consecutive attestations for EHR incentive program.
- Applied working knowledge of Health Information Management Standards of coding to ongoing evaluation of medical record documentation.
- Implement strategies for sustained work process changes that facilitate complete, accurate clinical documentation.
- Facilitated multidisciplinary team in efforts for clinical documentation improvement.
- Worked independently with minimum direction, anticipate and organize workflow, prioritize and follow through on responsibilities
6-10 years of experience
- Selected to lead an interdisciplinary group of Occupational, Physical, Speech Language Therapists in the design, content, workflow, training, and implementation of documentation for organization’s newly acquired Electronic Health Record-Cerner Corporation
- Collaborated with Cerner in design, build, testing, and implementation of new PT/OT/SLP and other modules
- Ensured regulatory compliance of documentation to demonstrate skilled service, meet standards, and increase revenue
- Served as Clinical Sales Lead and Subject Matter Expert of rehabilitation content to external rehabilitation providers delivering high end presentations, demonstrations, and round table discussions with C-Suite and other operational managers
- Exceeded sales goals year over year resulting in over 60 new contracts yielding several million dollars in revenue for both Cerner Corporation and RIC
0-5 years of experience
Resolve or clarify diagnoses with conflicting, missing, or unclear information by consulting with doctors or others or by participating in the coding team’s regular meetings.
- Was instrumental in positive reimbursement shifts in 48 charts in one month
- Maintained accurate, detailed reports and records
- Utilized knowledge of hospital operations, units, coding systems and medical staff physicians to detect clinical documentation problems
- Trained physicians in ICD-9 coding of SIRS & PNA as PDx for best reimbursement
0-5 years of experience
Concurrent Coding based on ICD-9
- Has worked in multiple specialty to include General Surgery, Internal Medicine, Psychiatry, Oncology
- Standard cases reviewed 15-20cases/day; but has viewed as many as 20-30 cases/day
- Oversaw cases at two separate sites
- Audited charts and improved documentation
- Composed queries as required
- Interacted and contributed to Case Management meetings as CDI Specialist
- Provided Intequal and Milliman Admission criteria as required
0-5 years of experience
Managed day to day activities of the Data Review Team (DRT), program data bases to ensure completion and accuracy
- Lead, facilitate and support teams improving processes involved in the design and execution of clinical trials, up to and through implementation
- Ensure identification, communication and adoption of best practices in clinical trials and submissions
- Participated in cross-functional continuous Clinical Development functions improvement
- Interacted with cross-functional components of Clinical Study Teams supporting in delivering data from major reporting events according to established goals
- Supported compliance with SOP’s
0-5 years of experience
Collaborated with utilization managers, nursing staff, and other ancillary staff regarding interaction with physicians on documentation improvement.
- Assisted coders with concurrent review of inpatient medical records and discussed documentation opportunities with physicians.
- Collaborated with coders and case managers, reviewing inpatient medical records to ensure correct Diagnosis-Related Group (DRG) assignment.
- Monitored and evaluated effectiveness of chart reviews and query outcomes. Performed monthly closed chart reviews.
- Communicated with individual physicians and medical staff departments to facilitate complete and accurate documentation.
0-5 years of experience
Monitored patient charts to ensure physician’s documentation mirrored patient acuity.
- Interacted with case managers to identify additional diagnosis that justified LOS.
- Collaborated with physicians, nurse practitioner, and physicians’ assistants in response to changes in patient acuity.
- Administered education to physicians, nurse practitioners, and physicians’ assistants in regards RAC Auditors.
- Queried physicians for documentation clarification when admitting diagnosis appeared ambiguous.
- Helped coders identify secondary diagnosis that increase case mix index and relative weight.
0-5 years of experience
Perform daily chart audits for multiple providers to ensure that documentation is accurate and correct per Medicare standards
- Instructed multiple physicians on Risk Adjustment and Coding Guidelines
- Responsible for conducting education for assigned providers and administrative staff within the providers organization on Risk Adjustment, ICD 9 codes, HCC methodology, HEDIS/Quality Measures (chief operational initiatives), and STARS measures.
- Assist PCP with proving cost effective care for Medicare Advantage members
- Case Managed around 3,000 Medicare Advantage patients for multiple physicians
- Case Managed patients to help decrease post hospital re-admissions
0-5 years of experience
- Completed concurrent documentation review to facilitate appropriate DRG assignment
- Interacted effectively with physicians regarding documentation appropriate to diagnosis and severity of illness
- Ensured clinical issues are reviewed with coding staff to assign an appropriate final DRG
- Developed and monitored metrics to assess impact of and performance opportunities for Clinical Documentation initiatives. Presented metrics with analysis and recommendations to Supervisor.
0-5 years of experience
Perform concurrent review of medical records for identified payer populations like Medicare, Medical and private prayers
- Promoted accurate documentation of medical necessity including appropriate admission status, severity of illness, proper MS -DRG assignment, financial reimbursement, case mix indexing and daily census.
- Educate and communicate with physicians and other staff as needed to foster collaborative working relationships
- Perform follow-up reviews to ensure issues needing clarification have been documented and communicate with CNO & CEO on monthly basis.
- Work closely with Professional coders to assure documentation of discharge diagnoses and any co-existing co-morbidities to accurately reflect patient’s clinical status
0-5 years of experience
Ensured the accuracy of provider chart dictation for billing of services according to the CDIP guidelines.
- Assigned accurate codes for diagnoses, treatments, and procedures according to the appropriate classification system for outpatient encounters.
- Utilized technical coding principals to assign appropriate ICD-9-CM diagnoses.
- Coordinated clinical documentation improvement opportunities for medical staff and allied health professionals.
- Rectified pre-bill coding related edits and coded related denials.
- Informed providers of policy and regulation changes and any updates to the billing charge tickets.
0-5 years of experience
Worked as part of case management performing chart reviews for coding and reimbursement purposes:
- Collaborated with coding specialists to ensure proper coding and billing for Medicare
- Collaborated with physicians to ensure proper documentation needs for correct coding and billing needs
- Performed teaching seminars for nursing, physician and coding staff to bring new documentation and coding needs to light according to ICD-9 and ICD-10 reimbursement policies
0-5 years of experience
Performed care delivery documentation system and related medical records documents.
- Worked closely with the medical staff to facilitate appropriate clinical documentation of services provided.
- Performed independently in a time-oriented environment.
- Conducted clinically based concurrent and retrospective reviews of inpatients medical records to evaluate the clinical documentation for reflective quality of care outcomes and reimbursement compliance for acute care services provided.
0-5 years of experience
- Collaborated with healthcare providers to improve the quality and completeness of documentation for the care provided
- Appropriate DRG assignment and procedures to reflect and support severity of illness and risk of mortality
- Team leader for [company name] over a team of 8 CDS, acted as preceptor for new CDI staff, organization of daily assignments, and adjustments of coverage as needed driven by census
0-5 years of experience
Concurrent chart review for acuity/specificity of disease processes for inpatient admissions hospital wide
- Provide physician/staff education on the importance of accurate/specific clinical documentation
- Responsible for hard copy/TDS and/or verbal physician queries on patient disease processes/acuities/severities in order to provide clinical accuracy for acuity/hospital reimbursement purpose
- Work closely with case management and all medical staff in order to ensure accuracy of clinical documentation/decrease in length of stay/quality/core measures
- Medicare reporting of all Restraint Deaths for accuracy and clinical necessity
- Clinical Liaison between Physicians and Health Information Management Staff
- Provide physician education on upcoming ICD-10 implementation for October 2014
0-5 years of experience
Responsible for medical record review to insure quality documentation to accurately reflect patient’s severity of illness and risk of mortality
- Collaborate with providers to clarify incomplete diagnosis in medical records
- Using clinical judgment to identify clinical indicators and query physicians for presence of other diagnosis
- Education of providers in the area of documentation improvement to best reflect patient’s conditions
- Assigned to Medical ICU
- Developed analytic reports to identify discharged medical records with potential documentation improvement opportunities
0-5 years of experience
Perform concurrent reviews of medical records to ensure accurate documentation of medical necessity. These reviews include an assessment of severity of illness/risk of mortality, correct MS-DRG assignment, appropriate revenue capture, case mix index, and support for Core and Quality Measures.
- Perform follow-up reviews to ensure diagnostic clarification queries have been answered.
- Educate physicians and other healthcare professionals as needed regarding the relationships between documentation, coding, and quality.
- Perform daily geometric mean length of stay (GMLOS) assignments on all inpatient cases, based on the working DRG for each case.
- Formulate CDI queries [online and written] based on clinical indicators in compliance with organizational and federal [CMS/AHIMA] guidelines.
- Educate CDI physician advisors on best practices for accurate coding and documentation.
- Maintain CDI monitor database including response rate (99%), agreement rate (98%), tracking and trending of diagnosis clarification queries.
- Collaborate with the coding department to ensure proper documentation of discharge diagnoses and comorbidities, in order to accurately reflect patients’ medical records.
0-5 years of experience
- Knowledgeable of ICD-10 CM and PCS coding principles and procedures
- Interacted with physicians to ensure clinical documentation accurately reflected the level of service rendered to the patient and that coding could be completed.
- Formulated detailed and concise queries regarding patient documentation and care for physician review and completion.
- Monitored cases for severity of illness, risk of mortality data, quality control issues, physician and hospital outcomes.
- Utilized software system, Epic and 3M, to track data and report outcomes
0-5 years of experience
- Clinical Documentation Specialist and coder (ICD-9 and ICD-10) of outpatient clinics (day surgery and wound care clinics)
- Reviews clinic charts and works closely with the doctors, nurses, and ancillary staff of clinics in order to improve documentation through clinic visits and queries.
- Inpatient Clinical Documentation Specialist (occasional)
- Attended weekly length of stay meetings, met with Chief Medical Officer to discuss selected cases, reviewed medical records and communicated in person and through queries in order to improve documentation
0-5 years of experience
Review Medicare and Medicare HMO charts to identify that the clinical documentation reflects the care given to patient during hospitalization.
- Identify query opportunities on each case and implement effective query process.
- Work with various physician groups on continual education of DRG’s, co-morbities and major co-morbities for appropriate documentation of each case.
- Active participation in daily huddle meetings with physicians, case managers, discharge planning and shift leaders to discuss DRG’s and GLOS.
- Assign DRG for each case reviewed.
- Utilize 3M to code each chart reviewed.
- Active participation with continual coding education to prepare for ICD10.
- Effective utilization of Allscripts reports and data.
0-5 years of experience
- Provided specialized support to the Clinical Trial Team in planning, execution, and control of clinical trial regulatory documentation
- Processed regulatory documentation associated with Clinical Study Start-up and Close-out.
- Monitored IRB approvals and annual renewals
- Compiled CSR appendices sections (per ICH E3 Guidelines).
6-10 years of experience
Review, examine, and use expert clinical knowledge base to ensure proper health record documentation by physicians.
- Expert knowledge of health care reform language
- Expert knowledge of JA Thomas and Associates CDMP software
- Expert knowledge of CMS and coding guidelines and continuing changes.
- Continuing education preparation and presentation for physicians and nurses.
- Multiple research and pilot projects for Chief Medical Officer
- In depth and on-going knowledge of ICD-9 coding system
Clinical Documentation Specialist Duties and Responsibilities
Based on job listings we analyzed, clinical documentation specialists’ duties typically involve:
Collecting Patient Information Clinical documentation specialists collect information from medical teams about patients’ diagnoses and enter it into a computer database for security. They conduct research and perform administrative duties as well.
Assess Medical Documents for Accuracy Clinical documentation specialists assess all medical documents for accuracy and ensure that records are systematically organized so that they can be easily located at a later date.
Check that Clinical Documents Comply with Laws Clinical documentation specialists check that all medical documents comply with federal laws in terms of how they are composed and stored. They are responsible for assessing systems and recommending strategies for improving the record keeping process to provide better service to staff and patients alike.
Prepare Written Reports Clinical documentation specialists work with staff to interpret reports to identify health-related patterns and assist in addressing health problems in patients, as well as preparing written reports for public health officials who evaluate the healthcare facilities.
Meet with Clinical Staff to Explain Reports Clinical documentation specialists meet with clinical staff to explain reports. This involves applying their knowledge of medical terminology and procedures to evaluate clinical documents and address any issues in the reports.
Clinical Documentation Specialist Skills and Qualifications
Typically, employers require an associate’s degree and several years’ experience in a similar role, as well as the following abilities:
- Detail oriented – clinical documentation specialists work with medical documents and clinical assessments to identify problems or trends, so having good attention to detail is important to ensure that nothing of importance is missed or ignored
- Interpersonal skills – excellent interpersonal and communication skills are necessary to remain polite, courteous, and professional while dealing with a variety of different people in different roles
- Critical thinking skills – clinical documentation specialists analyze medical information to provide better service to patients and to apply medical knowledge to evaluate clinical documents, requiring effective problem-solving skills
- Confidentiality – clinical documentation specialists work with confidential information on a daily basis, so they should have knowledge of privacy laws and maintain a level of confidentiality to protect patients.
- Training – clinical documentation specialists train information specialists on the proper methods of documentation and maintaining medical records properly, and teach medical coders standard procedures to follow when composing medical documents
Clinical Documentation Specialist Education and Training
The minimum requirement to become a clinical is an associate’s degree in health information technology. These programs often include computer training, how to access medical record information systems, and medical coding and terminology. More advanced qualifications include a bachelor’s degree in health services, public health, or care administration. Some employers may require work experience in addition to a formal qualification. Graduates from health information technology associate’s programs can also earn AHIMA’s Registered Health Information Technician (RHIT) credential as well. Clinical documentation specialists are expected to continue their education to stay up to date with the latest laws governing patient information.
Clinical Documentation Specialist Salary and Outlook
The median annual salary for clinical documentation specialists is nearly $69,000. Clinical documentation specialists in the 10th percentile earn around $48,000 annually, while the highest paid earn close to $93,000 a year. Some companies have bonus structures which can offer up to $6,000 in additional income. Location and level of experience impact the pay level; many employers offer dental plans and medical insurance as part of their benefits package. The Bureau of Labor Statistics predicts the growth rate for this sector to grow by 13 percent through 2026.
Helpful Resources
We’ve collected some of the best resources to help you develop a career as a clinical documentation specialist:
The Clinical Documentation Improvement Specialist’s Guide to ICD-10 – This revised version of a trusted reference guide explains the ICD-10 documentation and clinical indicators those working as a clinical documentation specialist may come across. It covers the latest tested tips and tools, as well as strategies to implement successful programs.
Clinical Documentation Improvement Specialists Handbook – This book aims to be an inclusive reference for clinical documentation specialist professionals. It covers the fundamentals of coding, querying physicians, and helps to develop strong interdepartmental communication.
ACDIS – The Association for Clinical Documentation Improvement Specialists site is packed with useful information that will help anyone beginning a career in this field, or those who want to stay up to date with the latest developments. The resource library, in particular, is a handy collection of whitepapers, webcasts, and more.
AHIMA Journal – The American Health Information Management Association’s blog highlights best practices in health information management and the emerging issues in the field, such as privacy, security, and accuracy of patient information.
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Last edited by: Gabriela Barcenas, CPRW, Content Writer II -
Gabriela Barcenas
CPRW, Content Writer IIGabriela is a Certified Professional Resume Writer (CPRW) and career adviser. With 10 years of digital media experience and five years of resume writing expertise, her publication history includes fashion, education, travel, social justice, equitable design and career advice.
