Clinical Documentation Specialist with 3+ years of high-volume, multi-specialty chart review experience supporting physicians across 20+ specialties. Skilled in documenting patient encounters, validating clinical details, and entering accurate data into EHR systems to support clean, complete, and compliant medical records. Strong in remote workflow efficiency, EMR navigation, and provider communication, with a consistent record of meeting productivity and accuracy expectations in fast-paced clinical environments. Brings adaptable, cross-functional experience from documentation, administrative support, and billing roles.
Overview
16
16
years of professional experience
Work History
Child Nutrition Specialist
Aramark
Orange Grove, TX
08.2025 - 05.2026
Supported daily school nutrition operations by preparing and serving meals in alignment with USDA, state, and district food-safety standards.
Maintained accurate records of meal counts, inventory, and temperature logs to ensure compliance with regulatory requirements.
Followed strict hygiene, sanitation, and allergen-safety protocols to protect student health and meet audit-ready standards.
Coordinated with staff to streamline meal service workflows, reduce wait times, and maintain a safe, organized environment.
Communicated with students, faculty, and administrators to support a positive, efficient cafeteria experience.
Adapted quickly to fast-paced, high-volume service demands while maintaining accuracy, consistency, and safety.
Generated menus for 200 children based on preferences, wellness goals and dietary needs.
Developed and implemented nutrition education programs for children to promote healthy eating habits.
Collaborated with school staff to assess and improve menu offerings based on dietary guidelines.
Clinical Documentation Specialist
Nuance Communications (acquired by Microsoft) → Cognizant
Remote, TX, USA
07.2021 - 04.2025
Performed high-volume clinical documentation review and multi-specialty chart abstraction across 20+ specialties, completing approximately 30 charts per day in a metric-driven remote environment.
Reviewed histories, physical exams, labs, imaging, medications, referrals, and diagnoses to ensure accurate, complete, and clinically aligned documentation.
Entered and validated clinical data in multiple EMRs, resolving unclear or missing information to support accurate provider documentation.
Maintained strong accuracy and consistency while navigating complex specialty-specific workflows and adapting to evolving documentation standards.
Ensured documentation supported ICD-10/CPT logic, payer requirements, and clean-claims workflows by identifying missing or inconsistent clinical details.
Identified documentation gaps affecting quality measures and payer alignment, escalating issues appropriately to support compliance and workflow accuracy.
Collaborated with clinicians and cross-functional teams to clarify documentation, resolve discrepancies, and support efficient clinical operations.
Adapted to workflow changes during the Microsoft acquisition and transition to Cognizant, maintaining productivity and documentation quality across multiple platforms and EMRs.
Ensured accuracy of clinical documentation to enhance patient care and compliance with regulatory standards.
Collaborated with healthcare providers to clarify and improve clinical narratives in electronic health records.
Conducted regular audits of documentation for quality assurance, identifying areas for improvement and training needs.
Mentored junior staff on best practices for clinical documentation, fostering a culture of continuous learning and improvement.
Implemented feedback mechanisms for real-time updates on documentation practices, enhancing overall accuracy and compliance.
Reduced risk exposure by promptly addressing any identified discrepancies or inconsistencies within patient records.
Processed records quickly to avoid delays and keep workflows running smoothly.
Supported daily clinic operations by reviewing patient information and medical records for accuracy, completeness, and proper documentation workflows.
Assigned diagnosis and procedure codes, prepared claims, and submitted them to insurance payers in alignment with billing and reimbursement guidelines.
Investigated and resolved unpaid or denied claims, communicating with payers to secure timely reimbursement and reduce outstanding balances.
Served as a key point of contact for patients, insurance companies, and clinical staff, ensuring smooth front-office operations and clear communication.
Managed scheduling, check-in, intake, and administrative tasks in a fast-paced rehabilitation clinic while maintaining HIPAA-aligned confidentiality and professionalism.
Answered phone calls and messages for 8 physician rehabilitation center, scheduling appointments, and handling patient inquiries.
Education
Diploma - Medical Insurance Billing And Coding
Everett Institute
Austin, TX
06-2010
Associates - Computer Design Technology
ITT Institute
Austin, TX
05-2007
GED - High School Equivalency
Austin Community College
Austin, TX
11-2004
Skills And Technical Proficiencies
Clinical documentation review
Multi-specialty chart abstraction
Documentation accuracy
Medical terminology
Clinical data entry (labs, imaging, histories, medications, referrals)
Provider communication
HIPAA-aligned workflows
ICD-10/CPT familiarity
Supports clean documentation for billing accuracy
Clarifying missing clinical details
Remote documentation workflows
Cross-functional communication
Cerner
Proprietary EMR systems
Extensive hands-on experience with Epic EHR systems
EHR navigation
Claims processing
Insurance verification
Front-office operations
Patient communication
Confidential records handling
Microsoft Office
Google Workspace
Zoom
Call-center platforms
Case-routing systems
Patient scheduling applications
Workflow management
Task prioritization
Health promotion
Meal planning
Sanitation procedures
Nutrition
Allergy awareness
Food portioning
Nutrition education
Kitchen equipment operations
Safe food handling
Timeline
Child Nutrition Specialist
Aramark
08.2025 - 05.2026
Clinical Documentation Specialist
Nuance Communications (acquired by Microsoft) → Cognizant