Stephanie Pedersen
Lincoln,NE
Summary
Accomplished Managing Consultant, specializing in Clinical Documentation Integrity, with a passion for educating and mentoring. Dedicated and adaptable professional with a proactive attitude and the ability to learn quickly. Strong work ethic and effective communication skills. Eager to contribute to a dynamic team and support organizational goals.
Overview
9
9
years of professional experience
1
1
Certification
Work History
Managing Consultant
Berkeley Research Group
07.2019 - Current
- Provides education and training to CDI staff, medical providers, and ancillary staff on effective, compliant clinical documentation.
- Facilitates consistent, accurate, optimal documentation by providing both formal and informal educational programs.
- Develops, implements, and coordinates formal CDI orientation program, including competency standards.
- Works with the analytic team, leadership, and the coding department to assess documentation gaps and formulate appropriate CDI educational tools, including, but not limited to, PowerPoint presentations and documentation tip sheets.
- Applies teaching/learning principles in establishing an overall educational program related to effective clinical documentation for, and in collaboration with, CDI staff, physicians, and the healthcare team.
- Provides education for all members of the patient care team on issues relating to clinical documentation.
- Acts as a resource to the CDI team and clinical providers on optimal clinical documentation.
- Developed and implemented project plans to ensure successful completion of consulting engagements.
- Facilitated client meetings to discuss progress, review deliverables, and identify areas of improvement.
- Identified opportunities for process improvements within client organizations through data-driven analysis.
- Assessed current organizational structures and recommended modifications for improved efficiency.
- Provided expertise on industry trends, regulatory requirements, best practices.
- Interviewed new job applicants to assess fit with company requirements and culture.
Clinical Documentation SpecialistConsultant
Harmony Healthcare - Talent and Consulting Solutions
01.2019 - 07.2019
- Consultant subcontracted to Prism Healthcare Partners (BRG).
- Mentor and support.
- Second-level reviews for documentation and education opportunities.
- Review concurrent inpatient documentation to identify and rectify inconsistencies, deficiencies, and discrepancies in medical documentation.
- Maintained updated knowledge of coding requirements.
- Education and support of physicians in optimizing inpatient documentation to maximize SOI/ROM through electronic queries and face-to-face communication.
- Decision trees, with or without the use of a grouper.
- Average daily review of 25-30 new cases and re-reviews, 85-90% follow-up of current cases, and complete reconciliation.
- Familiarity with root operations and CC/MCCs.
- Experience with multiple EMRs, including Cerner, Meditech, Care360, EPIC, 3M, Nuance, and QCPR.
Clinical Documentation Specialist
Addison Group
09.2017 - 09.2018
- Reviewed medical records to ensure accuracy and completeness of clinical documentation.
- Analyzed data from multiple sources including laboratory, radiology and pathology reports.
- Identified discrepancies in documentation with providers and resolved inconsistencies in a timely manner.
- Identified areas of risk related to incomplete or inaccurate documentation practices.
- Participated in regular meetings with physicians, nurses, case managers, coders, therapists. to discuss changes or improvements needed for clinical documentation processes.
- Maintained current knowledge of ICD-10 coding requirements, CPT and HCPCS coding systems, DRG assignment criteria and CMS regulations.
RN, Clinical Documentation Specialist
Adventist Health
06.2015 - 08.2017
- Reviewed medical records to ensure accuracy and completeness of clinical documentation.
- Identified discrepancies in documentation with providers and resolved inconsistencies in a timely manner.
- Monitored compliance with regulatory standards for the Clinical Documentation Improvement program.
- Developed and implemented policies and procedures related to clinical documentation improvement initiatives.
- Assisted physicians in development of comprehensive patient care plans through accurate coding and effective communication of results.
- Provided education to healthcare professionals on proper utilization of ICD-10 codes and other relevant coding guidelines.
- Collaborated with interdisciplinary teams to identify opportunities for improvement in clinical documentation processes.
- Generated monthly reports that reflect performance metrics related to CDI activities.
- Participated in regular meetings with physicians, nurses, case managers, coders, therapists. to discuss changes or improvements needed for clinical documentation processes.
- Maintained current knowledge of ICD-10 coding requirements, CPT and HCPCS coding systems, DRG assignment criteria and CMS regulations.
Education
ADN - Nursing
Southeast Community College
01.1997
Skills
- Healthcare Consulting
- Education
- Clinical Documentation Integrity
- Project Management
- Subject Matter Expert
- Client Engagement
- Meditech
- Epic Systems
- Cerner
- 3M Encoder
- Nuance
Certification
- Registered Nurse
- CCRN-Alumnus
- Certified Clinical Documentation Specialist (CCDS) - ACDIS
Timeline
Managing Consultant
Berkeley Research Group
07.2019 - Current
Clinical Documentation SpecialistConsultant
Harmony Healthcare - Talent and Consulting Solutions
01.2019 - 07.2019
Clinical Documentation Specialist
Addison Group
09.2017 - 09.2018
RN, Clinical Documentation Specialist
Adventist Health
06.2015 - 08.2017
- Registered Nurse
- CCRN-Alumnus
- Certified Clinical Documentation Specialist (CCDS) - ACDIS
ADN - Nursing
Southeast Community College
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