Salome Uzobuife
Fishkill,NY
Summary
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.
Overview
18
18
years of professional experience
1
1
Certification
Work History
Clinical Documentation Specialist
Memorial Sloane Kettering
2016.10 - Current
- Assesses patient's medical records for present-on-admission (POA) conditions ensuring accurate documentation regarding hospital acquired conditions (HAC, HCC), including CCs, MCCs
- Reviews PSIs, PDX, Point of Origin(POO), discharge Performs Clinical Documentation Quality Reviews to capture measures including Mortality, risk adjustment(RA), SOI, ROM, LOS by using various methodologies such as Vizient, Elixhauser
- Extensively reviews all physician and clinical documentation, including but not limited to diagnostic information, treatment plans and capturing appropriate information on CDMPA / 3M 360 Encompass (CAC) worksheets
- Utilizes clinical skills to identify documentation opportunities that reflect severity of illness, risk of mortality, acuity and resource consumption and when necessary will contact the appropriate physician ensuring documentation opportunities are clarified
- Routinely recognize and write new query opportunities for CDI on various topics including for cancer patients, complex pneumonias, Myocardial infarction, hepatorenal syndrome, Liver failure, Anemia specificity, etc
- Regularly attend seminars for continuing education on various coding and CDI topics
- Performed concurrent clinical documentation reviews on patients from admission to various units including all ICUs, medical - surgical to discharge
- Applied clinical and coding knowledge to query physicians on accurate diagnoses to reflect treatment rendered based upon severity of illness and risk of mortality
- Regularly created and developed new query opportunities related to many different body systems, including laboratory medicine, to reflect the patients' true clinical picture
- Captured coding opportunities with respect to PDX, CCs, MCCs and procedures to reflect SOI and ROM
- Communicated with and educated physicians on the importance of documentation accuracy and specificity for ICD10
- Participated in routine education, discussions and seminars on many clinical topics and query opportunities
- Attended ward rounds and gave presentations on various clinical documentation topics including Pneumonia, orthopedics, A - fib, etc
- Expertise using various programs including 3M 360, Epic, Iodine, Artifact and other various EMRs.
Epic Ambulatory Go-Live Support ATE SNY
Metropolitan Hosp, NY
2018.07 - 2019.01
- Assisted in the successful implementation of the Epic Ambulatory module, contributing to better patient care and data management
- Provided detailed project updates to stakeholders, ensuring they remained informed about the progress and milestones achieved during implementation phases
- Evaluated user feedback on system performance, making recommendations for improvements based on their input.
Chart Reviewer and Coding
Mount Vernon Medical Care
2012.01 - 2016.08
- 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
- Maintained monthly metrics tracking designated activities, Conducted comprehensive audits of medical charts, leading to enhanced data integrity and accuracy
- Increased interdepartmental collaboration by effectively communicating findings from chart reviews to relevant stakeholders throughout the organization
- Determined whether claims examiners or management questions could be appropriately addressed or referred to other team members.
Medical officer
Asokoro District Hospital
2008.03 - 2008.10
- Assessed the quality of health care system through procedures of internal audit and quality assurance involving financial, logistical, patient services and health management systems
- Managed the various aspects of a health care facility
- Performed quality assurance assessments of services within the healthcare system
- Convened with medical staff including doctors, nurses and practitioners to discuss procedures, policies and performance-related issues
- Developed business strategies of healthcare system.
Medical intern
University of Abuja Teaching Hospital
2007.02 - 2008.02
- Observed and assisted residents and attending physicians in OBGYN, surgery, pediatrics and internal medicine
- Completed medical charts, obtained patient histories and wrote prescriptions
- Researched and studied in order to be able to properly diagnose patients
- Attended meetings and reported back to superiors.
Education
Bachelor of Science - Nursing
Mount Saint Mary College
Newburgh, NY05.2024
M.D. - MBBS
University of Nigeria
Enugu12.2007
Bachelor of Science - Biological Sciences
University of Nigeria
ENUGU01.2002
Skills
- Documentation compliance
- Process Improvements
- Exemplary communication skills
- Proficient in [Software]
Certification
- CDIP: AHIMA
- CCS: ACDIS
- CPC: AAPC
- MBBS: NMA
- ECFMG: USMLE
Affiliations
- CCDS
- AHIMA
- AAPC
- HONOR SOCIETY
- Sigma Theta Tau
- ANA
- DOCTORS WITHOUT BORDERS
- NMA
Timeline
Epic Ambulatory Go-Live Support ATE SNY
Metropolitan Hosp, NY
2018.07 - 2019.01
Clinical Documentation Specialist
Memorial Sloane Kettering
2016.10 - Current
Chart Reviewer and Coding
Mount Vernon Medical Care
2012.01 - 2016.08
Medical officer
Asokoro District Hospital
2008.03 - 2008.10
Medical intern
University of Abuja Teaching Hospital
2007.02 - 2008.02
Bachelor of Science - Nursing
Mount Saint Mary College
M.D. - MBBS
University of Nigeria
Bachelor of Science - Biological Sciences
University of Nigeria
- CDIP: AHIMA
- CCS: ACDIS
- CPC: AAPC
- MBBS: NMA
- ECFMG: USMLE
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