Samreen Zafar
San Antonio,TX
Summary
Dynamic Clinical Documentation Specialist with Prime Healthcare Management, skilled in ICD 10 CM and effective communication. Enhanced documentation quality, driving revenue optimization through meticulous reviews and training initiatives. Proven ability to foster interdisciplinary collaboration and ensure compliance with regulatory standards, while leading teams to achieve high-quality outcomes.
Overview
6
6
years of professional experience
1
1
Certification
Work History
Clinical Documentation Specialist
Prime Healthcare Management
08.2022 - 05.2025
- Facilitated interdisciplinary collaboration between physicians, nurses, case managers, coders, and other relevant stakeholders regarding the appropriate representation of patient severity levels within EHRs.
- Assisted in the development of policies and procedures related to clinical documentation processes, promoting consistency across the organization.
- Communicated with physicians, nurses and other caregivers to explain importance of accurate and clear documentation.
- 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.
- Ensured compliance with regulatory standards and guidelines through meticulous attention to detail in completing clinical documentation tasks.
- Served as a resource for healthcare professionals seeking guidance on various aspects of clinical documentation, fostering effective communication among team members.
- Questioned physicians regarding missing or unclear health record documentation and requested further information for clarification purposes.
- Improved clinical documentation quality by conducting thorough reviews and providing feedback to healthcare providers.
- Trained and led a team of clinical documentation trainees, ensuring consistent development and high quality standards.
Clinical Extern
Dr. Hadi Dourra, MD
04.2021 - 04.2022
Clinical Observer
Garden City Hospital
09.2019 - 02.2020
- Shadowed experienced healthcare providers, learning valuable techniques for accurate diagnosis and effective treatment planning.
Education
M.B.B.S - Medicine
Rawalpindi Medical College
Rawalpindi, Pakistan01-2010
Skills
- ICD 10 CM
- CPT coding
- Epic systems
- 3M 360
- MS- DRG system
- APR- DRG system
- IPPS and OPPS payment system
- Team lead
- Physician advisor
- Concurrent and retro accounts review
- Query generation and good communication skills with physician
- HIPAA and PHI compliance
Accomplishments
Research Work:
Long term Mortality Trends in GI Neoplasms with liver Metastases: Insight from CDC Data
Mortality Trends in Diverticular Intestinal Disease in the United States: A population based CDC study
Certification
CDIP
CCS
Languages
English
Full Professional
Hindi
Native or Bilingual
Urdu
Native or Bilingual
Timeline
Clinical Documentation Specialist
Prime Healthcare Management
08.2022 - 05.2025
Clinical Extern
Dr. Hadi Dourra, MD
04.2021 - 04.2022
Clinical Observer
Garden City Hospital
09.2019 - 02.2020
M.B.B.S - Medicine
Rawalpindi Medical College
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