Proficient Clinical Documentation Specialist knowledgeable in evaluating medical records to determine accuracy and overall care quality. Talented professional with background in medical terminology, coding and team collaboration. Detail-oriented team player with strong organizational skills. Ability to handle multiple projects simultaneously with a high degree of accuracy.
Overview
30
30
years of professional experience
Work History
Clinical Documentation Specialist
Mass General Brigham Home Care
03.2016 - Current
Facilitated interdisciplinary collaboration between physicians, nurses, case managers, coders, and other relevant stakeholders regarding the appropriate representation of patient severity levels within EHRs.
Carefully reviewed patient files for clarity on diseases, diagnoses and procedures to determine quality of care.
Served as a resource for healthcare professionals seeking guidance on various aspects of clinical documentation, fostering effective communication among team members.
Analyzed data from audits to identify areas for improvement in clinical documentation processes, implementing targeted interventions for positive change.
Expedited accurate clinical documentation completion by promptly responding to queries from healthcare providers and support staff, offering timely guidance and support.
Reduced risk exposure by promptly addressing any identified discrepancies or inconsistencies within patient records.
Assisted in the development of policies and procedures related to clinical documentation processes, promoting consistency across the organization.
Effectively managed multiple priorities while maintaining strict adherence to established deadlines, ensuring the consistent delivery of exceptional clinical documentation services.
Maintained strong knowledge of medical terminology, diseases and conditions and procedures.
Collaborated with multidisciplinary teams to develop best practices in clinical documentation, streamlining processes and reducing errors.
Enhanced operational efficiency by streamlining quality assurance processes and documentation.
Collaborated with cross-functional teams for continuous improvement initiatives
Maintained high coding standards by adhering to industry best practices and staying current with emerging technologies.
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.
Reviewed patient charts to better understand health histories, diagnoses, and treatments.
Facilitated knowledge sharing within the team by conducting regular code reviews, training sessions, and workshops on relevant topics.
Actively participated in company-wide initiatives to foster a positive work environment, promote team-building activities, and champion continuous learning opportunities.
Resolved schedule conflicts swiftly, ensuring minimal disruption to operations and client satisfaction levels.
Analyzed departmental workloads to create balanced employee schedules while meeting business objectives.
Telehealth Nurse/ Interim Scheduling Manager
Hallmark Health VNA
01.2008 - 01.2011
Participated in quality improvement initiatives related to telehealth nursing practice, enhancing service delivery and patient experience.
Provided emotional support to patients during difficult times, promoting trust between nurse and patient through compassionate virtual interactions.
Assisted in the development of telehealth protocols and procedures, contributing to the overall success of the program.
Utilized evidence-based practices when delivering telehealth nursing services, ensuring safe and effective care for all patients.
Prioritized patient safety through diligent monitoring of vital signs while discussing any concerning changes or trends with appropriate healthcare providers promptly.
Participated in ongoing professional development opportunities related to telehealth nursing practice, staying current on industry trends and best practices.
Improved patient outcomes with thorough assessment, identification of potential issues, and prompt intervention via telehealth consultations.
Resolved schedule conflicts swiftly, ensuring minimal disruption to operations and client satisfaction levels.
Confirmed patient appointments via telephone to inform of appropriate preparations needed prior to examination.
Monitored ongoing projects closely, adjusting schedules as needed to accommodate unforeseen changes or delays.
Maintained open communication channels with clients and stakeholders to address scheduling concerns promptly.
Ensured compliance with labor laws and company policies when creating employee schedules, mitigating potential legal risks.
Primary Nurse Case Manager
Greater Medford VNA
05.1994 - 01.2008
Collaborated effectively with interdisciplinary teams, contributing to cohesive treatment approaches for optimal patient care.
Senior Director, Performance Improvement & Outcomes - Perioperative and Procedural at Mass General Brigham, Brigham & Women's HospitalSenior Director, Performance Improvement & Outcomes - Perioperative and Procedural at Mass General Brigham, Brigham & Women's Hospital