Carolyn Hereford
Huntington,United States
Summary
Proficient Clinical Documentation Improvement Specialist knowledgeable in evaluation of medical records to determine documentation accuracy , insure an accurate reflection of severity of illness, risk of mortality, complexity of care and utilization of resources. Professional with background in education and team collaboration for overall quality and completeness of the health record documentation.
Overview
24
24
years of professional experience
1
1
Certification
Work History
Clinical Documentation Improvement Specialist
St. Mary's Medical Center
Huntington , WV
03.2008 - 08.2022
- Communicated with physicians, nurses and other caregivers to explain importance of accurate and clear documentation.
- Reviewed charts concurrently and retrospectively for accurate reflection of severity of illness and risk of mortality.
- Maintained strong knowledge of medical terminology, diseases and conditions and procedures.
- Questioned physicians regarding missing or unclear health record documentation and requested further information for clarification purposes.
- Carefully reviewed patient records for clarity on diseases, diagnoses and procedures to determine quality of care.
- Input data into computer programs and filing systems.
- Maintained accuracy, completeness and security for medical records and health information.
- Compiled electronic patient records covering conditions, treatments and diagnoses.
- Used correct diagnosis-related groups based on patient encounter details.
- Compiled, abstracted and coded patient data using classification manuals and standard systems.
- Developed and implemented performance improvement strategies and plans to promote continuous improvement
Medical Coder
Probill
Huntington, WV
03.1998 - 09.2007
- Reviewed outpatient records and interpreted documentation to identify diagnoses and procedures.
- Reviewed, analyzed and managed coding of diagnostic and treatment procedures contained in outpatient medical records.
- Utilized active listening, interpersonal and telephone etiquette skills when communicating with others.
- Resourcefully used various coding books, procedure manuals and on-line encoders.
- Applied official coding conventions and rules from American Medical Association and Centers for Medicare and Medicaid Services to assign diagnostic codes.
- Used 3M to assign procedure and diagnostic codes to patient records for billing purposes.
Education
Licensed Practical Nursing - LPN
Cabell County Career Technology Center
Huntington, WV10.1997
Skills
- Medical Records and Documentation
- 3M Encoder
- Medical Records and Documentation
- EMR Systems
- ICD-10 coding
- DRGs Patient Assignments
- Attention to Detail
- Telephone Etiquette
- Knowledgeable about Diseases
- Hospital Inpatient and Outpatient Records
- Doctor Communication
- Microsoft PowerPoint
Certification
CCDS
- Certified Clinical Documentation Specialist, ACDIS - 6/2018
Timeline
Clinical Documentation Improvement Specialist
St. Mary's Medical Center
03.2008 - 08.2022
Medical Coder
Probill
03.1998 - 09.2007
Licensed Practical Nursing - LPN
Cabell County Career Technology Center
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