Responsible and dedicated Clinical Documentation Improvement Specialist (CDIS) with excellent, high-level communication skills demonstrated by five years of experience in an acute care hospital. Proven record of reliability and strong ability to establish rapport with patients and staff. Experience in documentation review in ICU, med-surg, telemetry, labor and delivery, and pediatric units.
CCS-Certified Coding Specialist
PRECYSE UNIVERSITY-2 year course in extensive ICD-10 training
*Assign diagnosis and procedure codes to both inpatient and outpatient charts based on specific clinical findings.
*Ensure improved documentation to support appropriate coding and reimbursement.
* Ensure that the PHIIP program is being applied appropriately and that the financial impact of the program is reported correctly.
*Possess an excellent understanding of coding practices, official guidelines and federal regulations.
*Maintain a broad knowledge of the clinical aspects of diagnoses, treatment, pharmacology and procedures.
*Maintain excellent auditing skills for coding quality and documentation
*Formulate compliant, non-leading queries to physician for documentation clarification requests
*Tracking and reporting of physician queries using the CDIS system as well as the PKMTR report
*Provide coders, senior leadership, and facility personnel orientation to documentation improvement activities
*Develop and present basic, intermediate, and advanced education for physicians, nursing, case management, Core measures, CFO, and administration personnel on DRG's, LOS, IPPS, and PHIIP program and practices
*Work with physician liaisons to improve physicians' understanding of the necessity of clear and concise documentation within charts and the impact that this documentation provides
*Keep abreast of regulatory changes related to inpatient coding and documentation, and communicate these changes to the appropriate corporate and hospital staff
*Assigned diagnosis and procedure codes to both inpatient and outpatient charts based on specific clinical findings (laboratory, radiology and, pathology reports as well as clinical studies) .
*Examined diagnosis codes for accuracy, completeness, specificity and appropriateness according to services rendered.
*Carefully coded disease and injury diagnoses, acuity of care and the corresponding E codes in an inpatient setting.
*Reviewed diagnostic and procedural terminology for consistency with acceptable medical nomenclature.
*Consistently ensured proper coding, sequencing of diagnoses and procedures.
*Quickly responded to staff and client inquiries regarding CPT codes.
*Appropriately and correctly identified errors and re-filed denied/rejected claims as they were received from the Patient Account Representative.
*Added modifiers as appropriate, coded narrative diagnoses and verified diagnoses.
*Completed appeals and filed and submitted claims.
*Recorded and filed patient data and medical records.
*Ensured compliance with medical/legal requirements, JCAHO standards and Army regulations.
*Carefully reviewed medical records for accuracy and completion as required by insurance companies.
*Achieved departmental goals and objectives by instituting new processes and standards.
*Prepared for HIPAA and JCAHO reviews, ensuring required brochures and pamphlets were available to patients in all clinics.
*Organized, updated and maintained all patient charts in an acute care hospital before converting to EHR
*Processed monthly reports for department performance.
*Maintained patient privacy and confidential patient information.
*Provided on-call assistance at all times of day and night for Medical Records Department (Prior to EHR's)
Completed an extensive 2 year course in ICD-10-CM and ICD-10-PCS coding, as well as the associated guidelines, regulations, and compliance standards.
**References will be promptly provided upon request**
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