Proficient Clinical Documentation Specialist knowledgeable in evaluating medical records to determine accuracy and overall quality of care. Experienced professional with background in medical terminology, coding, DRG assignments and team collaboration.
Maintained strong knowledge of medical terminology, diseases, conditions & procedures.
Processed records quickly to avoid delays and to keep the workflow running smoothly.
Verified accuracy and overall completeness of the medical record by auditing and reviewing patient information.
Reviewed the medical record for overall completeness and accuracy in documentation.
Communicated with physicians to obtain clarity on diseases, diagnoses and procedures for accuracy.
Worked with the medical coders to ensure accuracy of the patient's medical problem list before going to billing.
Worked closely with individual offices and the case management department at the hospital to ensure that patient's being discharged were appropriate and met the Medicare requirements for home health care services.
Provided patient and family education on the role of home health care services to ensure a smooth transition from the hospital to the home environment.
Patient advocate.
Worked closely with a team of professional nurses and physicians reviewing patient medical records to ensure their hospital status was correct on admission and throughout the patient's hospital stay.
Worked closely with insurance companies to obtain authorization for patient hospital stays.
Verified inpatient hospital diagnosis and documentation in the medical record to ensure accuracy prior to being sent to billing.
Health Record Documentation
EMR System
Documentation Compliance
Medical billing & Coding
CPR Certified
Medical Terminology
DRG Assignment
Charting and Clinical Documentation
Documentation Improvement
RN License
CPR certification