Rafael Uzcategui
Mission
Summary
Highly skilled Clinical Documentation Specialist with a proven track record of enhancing healthcare operations through meticulous record analysis, documentation improvement and compliance assurance, consistently finding ways to improve workflows and processes that save time and money. Adept at collaborating with multidisciplinary teams to ensure the accuracy of medical records, coding and revenue optimization
Overview
23
23
years of professional experience
Work History
Clinical Documentation Specialist II
Tenet Healthcare
01.2022 - Current
- Questioned physicians regarding missing or unclear health record documentation and requested further information for clarification purposes.
- Maintained strong knowledge of medical terminology, diseases and conditions and procedures.
- Carefully reviewed patient files for clarity on diseases, diagnoses and procedures to determine quality of care.
- Communicated with physicians, nurses and other caregivers to explain importance of accurate and clear documentation.
- Managed electronic clinical documentation and uploaded changes or updates using 3M, Cerner, Meditech, Epic
- Processed records quickly to avoid delays and keep workflows running smoothly.
- Verified accuracy and overall completeness of medical records by auditing and reviewing patient information.
- Audited and reviewed patient information via EMR management to verify accuracy and completeness.
Physician Assistant
Texas Federal Health and Rehab
01.2022 - 07.2023
- Conducted physical examinations to assess patients' health and current condition for optimal treatment.
- Managed chronic conditions by monitoring patient health and treatment plan progress to make necessary adjustments in care.
- Referred to and consulted with physicians and other healthcare providers on patient care.
- Ordered and interpreted diagnostic testing to confirm diagnosis and implement accurate treatment plans.
Clinical Documentation Specialist
Mission Regional Medical Center
04.2020 - 01.2022
- Questioned physicians regarding missing or unclear health record documentation and requested further information for clarification purposes.
- Lead a team of Clinical Documentation Specialists, providing guidance, training and mentorship to ensure consistent, high quality documentation practices
- Maintained strong knowledge of medical terminology, diseases and conditions and procedures.
- Carefully reviewed patient files for clarity on diseases, diagnoses and procedures to determine quality of care.
- Communicated with physicians, nurses and other caregivers to explain importance of accurate and clear documentation.
Clinical Documentation Specialist
Clinica Hispana
11.2018 - 03.2020
- Analyzed data from audits to identify areas for improvement in clinical documentation processes, implementing targeted interventions for positive change.
- Assisted in the development of policies and procedures related to clinical documentation processes, promoting consistency across the organization.
- Maintained strong knowledge of medical terminology, diseases and conditions and procedures.
- Contributed to revenue optimization by identifying opportunities for appropriate clinical documentation improvement.
- Carefully reviewed patient files for clarity on diseases, diagnoses and procedures to determine quality of care.
Medical Doctor
Medicine
Médico Cirujano
01.2002 - 11.2018
- Provided emergent medical care and treatment for life-threatening injuries and illnesses.
- Educated patients and families on benefits of healthy diet and adequate exercise.
- Ordered and executed various tests, analyses, and diagnostic images to provide information on patient condition.
- Diagnosed and treated patients suffering from chronic conditions.
Education
Physician Assisstant -
Arizona State Board
ArizonaM.D. -
Universidad Del Zulia
Venezuela12.2002
Skills
- Medical coding *(ICD-10, CPT, HCPCS)
- Clinical documentation improvement
- Compliance and regulatory knowledge
- Electronic health record (EHR) systems
- Strong interpersonal and communication skills
- Leadership and team management
- Revenue cycle management
Timeline
Clinical Documentation Specialist II
Tenet Healthcare
01.2022 - Current
Physician Assistant
Texas Federal Health and Rehab
01.2022 - 07.2023
Clinical Documentation Specialist
Mission Regional Medical Center
04.2020 - 01.2022
Clinical Documentation Specialist
Clinica Hispana
11.2018 - 03.2020
Medical Doctor
Medicine
Médico Cirujano
01.2002 - 11.2018
Physician Assisstant -
Arizona State Board
M.D. -
Universidad Del Zulia
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