Clinical Documentation Improvement (CDI) Specialist/ Coder Auditor with a focus on value-based care and the quality of patient care. With a strong understanding of medical coding, clinical documentation improvement, and healthcare administration, I prioritize the accurate and complete documentation of patient conditions while keeping costs under control. My exceptional communication and interpersonal skills allow me to work closely with healthcare providers to educate and implement best documentation practices, while also managing my time effectively to meet deadlines and deliver high-quality results. I bring a unique combination of medical knowledge, critical thinking, and adaptability to the healthcare system, always striving to improve the quality of patient care while ensuring cost-effectiveness. Committed to advancing value-based care in the healthcare industry, I am eager to bring my expertise to a new opportunity.
· Reviews and analyzes inpatient physician documentation present in the medical record for inpatient visits to ensure accuracy of diagnosis and procedure codes assigned by the Coders or Clinical Documentation Specialists (CDS) or Computer Assisted Coding (CAC) software.
· Retroactive CDS/Coder Auditor finalizes the coding and abstracting of the medical record upon ensuring the assignment of International Classifications of Diseases, Tenth revision (ICD 10 PCS), and Health Care Procedure Coding System (HCPCS), are accurate and supported by the clinical documentation of the respective medial record.
· Responsibility for DRG validation accuracy, primary role in assisting CDS and medical staff members with improving quality of clinical documentation.
· Communicating with facility CDS to place Physician Query Retrospectively regarding DRG optimization or conflicting documentation.
· Participates in chart review projects as assigned and other duties as needed.
· Use of an encoder software product for code assignment in an acute care setting
Communication and Interpersonal Skills
AHIMA | Certified Coding Specialist: October 2022
Simplilearn | Lean Six Sigma Green Belt Certification course: October 2021
IHI | IHI Open School Basic Certificate in Quality and Safety: November 2021
Optimization of Clinical Documentation Improvement Training Program at Prime Healthcare: From October 2022 to Present
Project Summary:
Utilization of CDI education training program to educate CDI and providers to establish the most accurate diagnoses to improve the quality and accuracy of medical claims and optimize reimbursement.