RUBEN M. ESCOBAR
El Paso,TX
Summary
Confident and proficient Clinical Documentation Specialist with almost 9 years of experience in the field, and more than 15 years of clinical/medical experience. Knowledgeable in evaluating medical records into detail to determine the most accurate clinical picture, ensuring on reflecting the appropriate SOI/ROM, and facilitating positive outcomes to the medical record through close collaboration with healthcare providers. Always on the look for ways to improve the workflow and the outcomes from the interaction between Providers, Coders and Administrative teams.
Overview
18
18
years of professional experience
1
1
Certification
Work History
Clinical Documentation Integrity Specialist
Tenet Hospitals. The Hospitals of Providence
12.2015 - Current
- Review the entire chart for every admission on a daily and concurrent (inpatient) basis, focusing on Physicians notes (H&P’s, Progress Notes, Consultation Reports, Operative Reports) in order to assist them on providing the most specific Documentation/Diagnoses, along with capturing the appropriate DRG by establishing a Principal diagnosis, and accurate Severity of Illness and Risk of Mortality through the secondary diagnoses, as well as the acuity of the condition/s of why the patient is hospitalized and the resources being used
- Responsible on identifying the patients Severity of Illness and Risk of Mortality to make it suitable for their GLOS (Geometrical Length of Stay)
- Identify deficiencies and lack of specificity in the documentation of both, chronic and new onset diagnoses
- In case any documentation deficiencies are detected, a Query should be initiated to ask the corresponding provider for a specific response, with the purpose of obtaining the most accurate clinical picture of every admission
- Constant interaction with Physicians (discuss diagnoses and treatment plan)
- Educate Providers on certain topics/diagnosis, Queries and Coding guidelines
- Elbow to elbow education on non-compliant Physicians, followed by making rounds with them when prompted
- Attending administrative meetings when prompted by directors
- Cross cover (review cases) for other Facilities in this region/Market (Memorial Campus, Sierra Campus, East Campus)
- Cross cover/reviews for cases from different Markets (Alabama, Memphis, Palm Beach, San Antonio) when prompted or when OT is offered
- In Charge of reviewing Pediatric cases (Pediatric cases are not reviewed by every CDIS)
- Work along the Coding department to ensure the documentation is the most accurate and specific before it is final coded by them
- Create and provide educational presentations for Physicians, Residents, RN’s, PA’s, Nurse Practitioners, coders and administrative personnel when prompted, with the whole purpose of maintaining a constant and up to date education of the most frequent and severe comorbidities to ensure quality of care towards every patient
- 3rd year Residents learning rotations from the program of Business of Medicine. Every month, Residents rotate for a few hours through this department with the intention of learning about the CDI role and the Query process, including how their query responses make an impact on their patients’ hospital stay and quality of care (DRG, SOI/ROM, GLOS).
Roberto Canales M.D.P.A
Clinical Coordinator/Office Manager
08.2013 - 12.2015
- Responsible for the following: Coordinating the Clinic’s daily operation
- Assuming full responsibility of managing every situation the practice can encounter day by day, either with patients, parents or the same staff
- Implementing a strategy to make the Patient flow the most Time-efficient possible to avoid long waiting hours
- Evaluating the needs of every department, being ready to provide backup where it may be needed it
- For same reason, full knowledge/skills on every department was needed (front desk, MA’s, Scribes)
- Assisting Providers when needed
- This includes translations, during “rush hours” as scribe, during procedures, etc
- Training and motivating the staff to improve the quality of service and with any updates needed in the Practice
- Review and prepare the daily chart audit
- Done in an hourly basis
- Discuss and participate with Providers about the Diagnosis and treatment plan of a respective patient when insufficient clinical data has been documented on the chart, to improve the quality of care in each patient
- Review selected Patient’s Charts when requested by Insurance Companies for Regulatory Audits
- Closing the shift
- (Finalizing the daily charts Audit, supervising the total of payments/charges received/done on a daily basis)
- Assuming full responsibility for the entire office, assuring the inventories (medical/office supplies) and a complete staff will be ready for the upcoming shift.
Roberto Canales M.D.P.A.
Clinician Assistant/Scribe
02.2010 - 12.2015
- Responsible for the following: Clinical attention, education, and assessment to patients over the telephone
- Assisting Dr Roberto Canales during consultation, performing scribe duties
- Performing documentation procedures on charts, progress notes and laboratory and/or image test orders, as well as prescription writing and handling
- Manage patient information over the electronic medical record (Office Practicum Software)
- Assist other physicians performing scribe duties
- Review lab work, and image tests results to update medical records and/or to explain to patient’s and their parents
- Review foreign hospital visits, and external specialist consultations for patient follow up
- Assist pharmacies, school nurses, and external physicians on patients management
- Help patients with Insurance approval for their medications with constant pharmacy and Insurance companies interaction/communication.
Hospital Zaragoza
Primary Care and Basic Specialty Medical Center
09.2008 - 02.2010
- Maternal and Newborn Statistical Department Coordinator
- Primary Care Physician: Family Medicine
- Covering ER department night shifts
- Surgical assistant for General Surgeons, Orthopedic Surgeons, Ob/Gyn Surgeons
- Cooperative patient diagnosis, treatment and management with basic specialists (pediatrics, internal medicine, surgery and orthopedics).
Social Service
Chihuahua State Health Services
08.2007 - 08.2008
- Living in a Rural Clinic for 1 year round, taking care of the clinical tasks on the local community
- Practicing as Primary Care Physician for Basuchil County community in a non-profit basis
- Managing the preventive areas of the community, like vaccination campaigns, chronic degenerative diseases, family planning programs, and community census
- Giving Educational presentations to the Community about Public Health and local health topics
- Creating a final demographic test of the whole community with future health planning programs.
Medical School Internship
General Hospital Zone #6 IMSS
07.2006 - 07.2007
- Rotation through the following services: Obstetrics/Gynecology, Pediatrics, Family Medicine, Emergency Medicine, Internal Medicine, General Surgery
- Documentation procedures such as chart dictations, lab work and image tests interpretation
- Labor & delivery assessment and deliver newborns
- Assisting surgeries as 1st and 2nd assistant
- Working 36 hour shifts in an A B C round basis
- Supervise and educate medical students during their clinical service
- Clinical case and educational presentations on every service as a requisite to switch from one service to another
- Final Thesis work on “In hospital Morbidity on Patients with Peritoneal Dialysis”.
Education
High School -
Cathedral High School
El Paso, TX06.2001
Medical School - Medicine
Universidad Autónoma De Ciudad Juárez (UACJ)
Ciudad Juarez, Chih.06.2006
Skills
- Skillful user of Cerner Power Chart, 3M 360 and Iodine-Interact Medical software
- Excellent relationship/rapport with Physicians, Mid Level Providers and Admin Personnel
- Office Practicum and Medical Manager Electronic Medical Records (Pediatric EMR)
- Coding guidelines proficiency
- Scribe and dictate clinical notes (H&P’s, progress and discharge summaries)
- Knowledge and expertise in medical terminology
- Microsoft Office (word, excel, powerpoint, outlook)
- MacOS (Pages, numbers, keynote)
- Bilingual (Spanish-English domain)
- Excellent interpersonal relationships
- Management and supervisor skills proficient
- Fast learner
Certification
- Certified Nurse Assistant, 2004
- ATLS (Advanced Trauma Life Support), 03/2009
Research/publications
- Clinical Case Presentation, Neurological Damage Regression with Endarterectomy Procedure, Medical Student Congress Surgical Upgrades and other Medical Areas, ¨Universidad Autónoma de Chihuahua¨, 2006
- Clinical Study Presentation, Left Ventricle Hypertrophy Regression with antihypertensive agents, Medical Student Congress Surgical Upgrades and other Medical Areas, ¨Universidad Autónoma de Chihuahua¨, 2006
Training
- Medical Student Congress II, Universidad Autónoma de Ciudad Juárez (UACJ), 2001
- Medical Student Congress III, Universidad Autónoma de Ciudad Juárez (UACJ), 2002
- Medical Student Congress ITESM, Instituto Tecnológico y de Estudios Superiores de Monterrey, 2002
- Medical Student Congress IV, Universidad Autónoma de Ciudad Juárez (UACJ), 2003
- Medical Student Congress V, Universidad Autónoma de Ciudad Juárez (UACJ), 2004
- Medical Student Congress VI, Universidad Autónoma de Ciudad Juárez (UACJ), 2005
- 1st Surgical Symposium Dr. Gregorio De la Fuente, Nuevo Casas Grandes, Chihuahua, 2008
- El Paso First and Superior Trainings, El Paso, TX, 01/2015
- CDIS Boot Camp, Dallas, TX, 08/2016
- CDIS Boot Camp, El Paso, TX, 02/2019
Timeline
Clinical Documentation Integrity Specialist
Tenet Hospitals. The Hospitals of Providence
12.2015 - Current
Roberto Canales M.D.P.A
Clinical Coordinator/Office Manager
08.2013 - 12.2015
Roberto Canales M.D.P.A.
Clinician Assistant/Scribe
02.2010 - 12.2015
Hospital Zaragoza
Primary Care and Basic Specialty Medical Center
09.2008 - 02.2010
Social Service
Chihuahua State Health Services
08.2007 - 08.2008
Medical School Internship
General Hospital Zone #6 IMSS
07.2006 - 07.2007
- Certified Nurse Assistant, 2004
- ATLS (Advanced Trauma Life Support), 03/2009
High School -
Cathedral High School
Medical School - Medicine
Universidad Autónoma De Ciudad Juárez (UACJ)
Similar Profiles
Jessica LoyJessica Loy
Physician Recruiter at Tenet – The Hospitals of Providence/Tenet Physician Resources (TPR)Physician Recruiter at Tenet – The Hospitals of Providence/Tenet Physician Resources (TPR)
Kyanna AlvarezKyanna Alvarez
Registered Nurse, Cardiac Telemetry at THE HOSPITALS OF PROVIDENCE TRANSMOUNTAINRegistered Nurse, Cardiac Telemetry at THE HOSPITALS OF PROVIDENCE TRANSMOUNTAIN
JESSICA GERAKJESSICA GERAK
Registered Charge Nurse, Emergency Department at The Hospitals Of Providence TransmountainRegistered Charge Nurse, Emergency Department at The Hospitals Of Providence Transmountain