Rajesh Sah, MD, CCDS
Columbia,SC
Summary
Foreign medical graduate and seasoned clinical documentation specialist with a proven track record at Prime Healthcare Services, enhancing patient care quality through meticulous record auditing and ICD-10 coding. Spearheaded educational initiatives, significantly improving documentation accuracy and compliance. Renowned for exceptional communication skills and a strategic approach to data analysis, driving operational excellence and regulatory adherence.
Overview
9
9
years of professional experience
1
1
Certification
Work History
Associate Group Practice Manager
Veterans Health Administration VHA
Columbia, SC
11.2023 - Current
- Implemented strategies designed to reduce wait times, improve appointment scheduling accuracy.
- Ensured understanding of policies and procedures among clinical service line staff.
- Created reports on patient access metrics, such as wait times, no-shows.
- Analyzed data from various sources to identify trends in patient access operations.
- Evaluated existing processes for efficiency and made recommendations for improvements.
- Managed customer service issues related to patient access and scheduling problems.
- Served as a liaison between clinical teams and administrative teams within the organization.
- Identified opportunities to increase operational efficiencies through process changes or technological solutions.
- Assessed need for additional staff, equipment and services based on historical data and seasonal trends.
- Established solid relations with leadership and staff by attending board meetings and coordinating interdepartmental information exchanges.
- Assisted in the management of staffing schedules to meet fluctuating demands.
- Collaborated with multi-disciplinary staff to improve overall patient care and response times.
- Developed and implemented patient access policies and procedures.
- Collaborated with stakeholders in developing strategies designed to improve patient satisfaction scores related to access services.
- Prioritized and organized tasks to efficiently accomplish service goals.
Clinical Documentation Specialist
Veterans Health Administration VHA
New York, NY
06.2019 - 11.2023
- Created educational materials related to best practices for accurate clinical documentation across all settings.
- Determined quality of care provided to patients through careful assessment of medical documentation.
- Explained to entire healthcare team importance of providing in-depth, accurate medical records and documentation
- Participated in regular meetings with physicians, nurses, case managers, coders, therapists. to discuss changes or improvements needed for clinical documentation processes.
- Completed in-depth audits of performance and quality of current charts and processes through facility reviews.
- Maintained current knowledge of ICD-10 coding requirements, CPT and HCPCS coding systems, DRG assignment criteria and CMS regulations.
- Uncovered discrepancies in health records and contacted physicians to provide further documentation to clarify concerns.
- Developed and implemented policies and procedures related to clinical documentation improvement initiatives.
- Acquired strong background in medical terms, illnesses and conditions and medical procedures.
- Generated monthly reports that reflect performance metrics related to CDI activities.
- Identified areas of risk related to incomplete or inaccurate documentation practices.
- Developed strategies designed to improve quality outcomes associated with specific diagnosis groups.
- Monitored compliance with regulatory standards for the Clinical Documentation Improvement program.
- Reviewed all discharge summaries to ensure they meet quality standards as defined by the Joint Commission.
- Analyzed data from multiple sources including laboratory, radiology and pathology reports.
- Maximized accuracy and completeness of medical records through in-depth audits and patient information reviews.
- Identified discrepancies in documentation with providers and resolved inconsistencies in a timely manner.
- Reviewed medical records to ensure accuracy and completeness of clinical documentation.
Clinical Documentation Specialist
Sage West Hospital
Lander, WY
07.2017 - 05.2019
- Reviewed diagnostic and procedural terminology for accuracy.
- Created educational materials related to best practices for accurate clinical documentation across all settings.
- Determined quality of care provided to patients through careful assessment of medical documentation.
- Explained to entire healthcare team importance of providing in-depth, accurate medical records and documentation
- Participated in regular meetings with physicians, nurses, case managers, coders, therapists. to discuss changes or improvements needed for clinical documentation processes.
- Completed in-depth audits of performance and quality of current charts and processes through facility reviews.
- Maintained current knowledge of ICD-10 coding requirements, CPT and HCPCS coding systems, DRG assignment criteria and CMS regulations.
- Uncovered discrepancies in health records and contacted physicians to provide further documentation to clarify concerns.
- Developed and implemented policies and procedures related to clinical documentation improvement initiatives.
- Developed strategies designed to improve quality outcomes associated with specific diagnosis groups.
- Monitored compliance with regulatory standards for the Clinical Documentation Improvement program.
- Reviewed all discharge summaries to ensure they meet quality standards as defined by the Joint Commission.
- Analyzed data from multiple sources including laboratory, radiology and pathology reports.
- Maximized accuracy and completeness of medical records through in-depth audits and patient information reviews.
Clinical Documentation Specialist
Prime Healthcare Services
Ontario, CA
09.2015 - 06.2017
- Created educational materials related to best practices for accurate clinical documentation across all settings.
- Determined quality of care provided to patients through careful assessment of medical documentation.
- Explained to entire healthcare team importance of providing in-depth, accurate medical records and documentation
- Participated in regular meetings with physicians, nurses, case managers, coders, therapists. to discuss changes or improvements needed for clinical documentation processes.
- Completed in-depth audits of performance and quality of current charts and processes through facility reviews.
- Reviewed diagnostic and procedural terminology for accuracy.
- Maintained current knowledge of ICD-10 coding requirements, CPT and HCPCS coding systems, DRG assignment criteria and CMS regulations.
- Reviewed diagnostic and procedural terminology for consistency with acceptable medical nomenclature.
- Uncovered discrepancies in health records and contacted physicians to provide further documentation to clarify concerns.
- Developed and implemented policies and procedures related to clinical documentation improvement initiatives.
- Acquired strong background in medical terms, illnesses and conditions and medical procedures.
- Generated monthly reports that reflect performance metrics related to CDI activities.
- Monitored compliance with regulatory standards for the Clinical Documentation Improvement program.
- Reviewed all discharge summaries to ensure they meet quality standards as defined by the Joint Commission.
- Analyzed data from multiple sources including laboratory, radiology and pathology reports.
- Maximized accuracy and completeness of medical records through in-depth audits and patient information reviews.
- Identified discrepancies in documentation with providers and resolved inconsistencies in a timely manner.
Education
M.D. - Medicine
Zhengzhou University
China07-2009
Skills
- ICD-10 coding
- Medical terminology
- Record auditing
- Quality assurance
- Regulatory compliance
- Educational material creation
- Data and trend analysis
- Exemplary communication skills
Certification
- CCDS (Certified Clinical Documentation Specialist) - ACDIS
- Epic Credentialed Ambulatory Trainer
Timeline
Associate Group Practice Manager
Veterans Health Administration VHA
11.2023 - Current
Clinical Documentation Specialist
Veterans Health Administration VHA
06.2019 - 11.2023
Clinical Documentation Specialist
Sage West Hospital
07.2017 - 05.2019
Clinical Documentation Specialist
Prime Healthcare Services
09.2015 - 06.2017
M.D. - Medicine
Zhengzhou University
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