Sheila
Milwaukee
Summary
Detail-oriented Clinical Documentation Specialist with proven skills in accuracy, regulatory compliance, and effective communication. Committed to enhancing patient care through diligent documentation practices.
Overview
25
25
years of professional experience
1
1
Certification
Work History
Clinical Documentation Specialist
Ascension
Shorewood
06.2020 - Current
- Reviewed clinical documentation for accuracy and compliance with guidelines.
- Collaborated with healthcare providers to clarify and improve documentation practices.
- Educated staff on proper documentation procedures and best practices.
- Analyzed medical records to ensure completeness and adherence to regulations.
- Coordinated with coding specialists to resolve discrepancies in documentation.
- Maintained up-to-date knowledge of regulatory changes affecting clinical documentation.
- Determined quality of care provided to patients through careful assessment of medical documentation.
- Reviewed medical records to ensure accuracy and completeness of clinical documentation.
- Uncovered discrepancies in health records and contacted physicians to provide further documentation to clarify concerns.
- Assisted physicians in development of comprehensive patient care plans through accurate coding and effective communication of results.
Compliance Specialist
Ascension
Brown Deer
10.2012 - 06.2020
- Reviewed compliance policies to ensure alignment with industry regulations.
- Conducted internal audits to assess adherence to compliance standards.
- Developed training materials for staff on compliance procedures and best practices.
- Collaborated with cross-functional teams to address compliance-related issues.
- Monitored regulatory changes and updated policies accordingly.
- Facilitated compliance training sessions for new employees and ongoing staff development.
- Analyzed risk areas to recommend improvements in compliance processes.
- Maintained accurate records of all activities related to compliance monitoring.
- Coordinated with various departments within the organization to ensure adherence to established standards.
- Assisted in developing strategies for improving overall compliance performance.
DRG Auditor
Meridian Resource Company, LLC
Brookfield
09.2011 - 10.2012
- Analyzed data for discrepancies and reported findings to management.
- Maintained up-to-date knowledge of regulatory changes affecting auditing practices.
- Conducted audits on internal controls and developed reports on findings.
- Collaborated closely with other team members to develop effective audit plans.
- Interacted regularly with clients to discuss audit progress, findings, and recommendations.
Coord-Quality & Patient Safety
Ascension
Milwaukee
06.2010 - 06.2011
- Analyzed data trends to identify areas for improvement and enhance patient safety initiatives.
- Collaborated closely with team members to identify areas for quality improvement and implement effective solutions.
- Collaborated closely with team members to achieve project objectives and meet deadlines.
- Utilized various software and tools to streamline processes and optimize performance.
IP Medical Coder
Ascension
Milwaukee
06.2001 - 06.2010
- Reviewed medical records for accurate coding and compliance with regulations.
- Utilized ICD-10 and CPT coding systems for various medical procedures.
- Collaborated with healthcare professionals to clarify documentation and coding issues.
- Maintained up-to-date knowledge of coding guidelines and industry changes.
- Communicated efficiently with billing department personnel regarding any changes made during the coding process.
Education
Associate of Science - Health Information Management
University of Detroit Mercy
Detroit, MI05-1985
Skills
- Clinical documentation
- Regulatory compliance
- Medical coding
- Audit coordination
- Quality assurance
- Risk assessment
Certification
Registered Health Information Technician AHIMA
Timeline
Clinical Documentation Specialist
Ascension
06.2020 - Current
Compliance Specialist
Ascension
10.2012 - 06.2020
DRG Auditor
Meridian Resource Company, LLC
09.2011 - 10.2012
Coord-Quality & Patient Safety
Ascension
06.2010 - 06.2011
IP Medical Coder
Ascension
06.2001 - 06.2010
Associate of Science - Health Information Management
University of Detroit Mercy