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Clinical documentation improvement specialist skills for your resume and career
15 clinical documentation improvement specialist skills for your resume and career
1. Patients
- Validated diagnostic codes and identified any missing diagnosis to ensure patients severity of illness was accurately reflected in the medical record.
- Prepared, maintained and updated clinical documentation ensuring completeness and accuracy of services provided to the patients.
2. Patient Care
Patient care entails the diagnosis, recovery, and control of sickness as well as the maintenance of physical and emotional well-being through the use of healthcare providers' services. Patient care is described as services provided to patients by health practitioners or non-professionals under guidance.
- Provided formalized education session for all members of the interdisciplinary patient care staff regarding clinical documentation opportunities and coding reimbursement issues
- Provided education to physicians and other patient caregivers on regulatory/reimbursement changes.
3. Clinical Documentation Improvement
- Worked collaboratively with physicians, medical record coding staff, and interdisciplinary teams to facilitate the clinical documentation improvement process.
- Facilitate clinical documentation improvement through the identification of documentation issues impacting revenue, severity and quality.
4. CCDS
- Obtained CCDS certification in 2016.
5. ICD-10
- Interacted directly with physicians to query for more specific documentation and to provide documentation guidelines from ICD-9 and ICD-10 standards.
- Transitioned from ICD-9 to ICD-10 by providing education, workshops and 1:1 meetings with the physicians and support staff.
6. CCS
- Generated queries for clarification or quality of the documentation and for MCCs, CCs.
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- Developed Physician Query Forms in accordance w/ AHIMA guidelines Attended and spoke @ monthly physician meetings - surgical, ortho, hospitalist
- Attended educational seminars for AHIMA certification and educated other staff as needed.
8. Clinical Documentation
Clinical documentation is a record specifying an instance of administered clinical therapy, clinical care, or a clinical test. Clinical reports should be exact, opportune, and reflect all instructions and advisements given to a patient.
- Monitor and evaluate effectiveness of concurrent chart review and query outcomes and reports to the Supervisor of Clinical Documentation.
- Formulated clinically credible documentation clarifications and followed up on all cases, included those with clinical documentation clarifications.
9. Concurrent Review
- Facilitated improvement in the overall quality, completeness and accuracy of medical record documentation through concurrent reviews of the medical records.
- Conduct clinically based initial and concurrent review of inpatient medical records to evaluate the documentation and utilization of acute care services.
10. Ms-Drg
- Collaborate with coders as needed to assure accurate documentation and assignment of Present on admissions and MS-DRG.
- Advanced knowledge and practice in navigating 3M Encoder in finding MS-DRG grouping and MS-DRG wt.
11. Documentation Issues
- Identify documentation issues such as quality, appropriateness, completeness, and communicate the issues to physicians.
- Assisted affiliated providers with coding and documentation issues as they arise.
12. CPT
CPT is a medical term that stands for Current Procedural Terminology. Whenever a procedure like surgery or diagnosis occurs or some other medical service is rendered to a patient, it is reported to the concerned physician, insurance company, or organization. The aforementioned practice is widely referred to as CPT.
- Participated with yearly updates for changes in CPT, ICD9/ICD10 codes, updating systems and paper encounter forms.
- Educated coders in the diagnoses, treatments and procedures to which they assign ICD-10-CM and CPT codes.
13. Cdis
- Worked as an RN on M/S until Sept 2015 initiated CDIS program
- Collaborate with other CDIS and Coders to achieve organizational goals.
14. POA
- Request documentation clarification as appropriate for SOI, ROM, POA, and VBP.
- Assign the correct POA status.
15. EMR
- Accessed Paragon EMR software for current clinical data information and HPF software for retrospective patient record information.
- Traveled to various offices, working remotely, on various EMR / EHR systems.
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List of clinical documentation improvement specialist skills to add to your resume
The most important skills for a clinical documentation improvement specialist resume and required skills for a clinical documentation improvement specialist to have include:
- Patients
- Patient Care
- Clinical Documentation Improvement
- CCDS
- ICD-10
- CCS
- AHIMA
- Clinical Documentation
- Concurrent Review
- Ms-Drg
- Documentation Issues
- CPT
- Cdis
- POA
- EMR
- Documentation Guidelines
- Medicaid
- Clinical Indicators
- Home Health
- Query Process
- Medical Necessity
- Acute Care
- ICD-9-CM
- Principal Diagnosis
- Core Measures
- Chart Review
- EHR
- Physician Education
- Diagnosis Codes
- CMI
- Patient Discharge
- Medical Charts
- Appeals
- Meditech
- Soi
- Patient Charts
- Patient Illness
Updated January 8, 2025
