Experienced Certified Clinical Documentation Specialist seeking to pursue advancement in my CDI career by taking additional responsibilities and exploring more advanced CDI concepts.
Overview
21
21
years of professional experience
1
1
Certification
Work History
Clinical Documentation Integrity Specialist
UT Southwestern Medical Center
07.2018 - Current
Performs concurrent initial and follow up reviews on patients EHR and determine completeness and accuracy of documentation and verify the appropriate DRG assigned and validated by documentation.
Utilize critical thinking and analytic skills to interpret charts to accurately reflect the patient's severity of illness and risks of mortality.
Initiates effective and compliant queries following appropriate guidelines.
Engaged providers by measured interactions and providing education as needed.
Clinical Documentation Integrity Specialist
Houston Methodist
01.2016 - 06.2018
Review concurrent inpatient medical records to identify and determine accuracy and completeness of documentation.
Initiates effective and compliant queries following appropriate guidelines.
Facilitates appropriate clinical documentation to ensure level of services and acuity of care are accurately reflected in the medical record.
Performs initial and follow up reviews to verify the appropriate DRG is assigned and validated by documentation.
Collaborate and educate healthcare providers on comprehensive health record documentation that reflects clinical treatment, diagnosis and interventions.
Assist in training newly hired CDI staff in ensuring accurate medical record reviews and formulating compliant queries and serves as resource for other team members.
Conduct second level review with mortality charts, longer length of stay and other charts and identify opportunities to clarify missing and incomplete documentation.
Patient Care Technician 6green Medical Surgical at Ut Southwestern Medical CenterPatient Care Technician 6green Medical Surgical at Ut Southwestern Medical Center