Clinical Documentation Specialist Resume Example

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Jessica Claire
  • Montgomery Street, San Francisco, CA 94105
  • H: (555) 432-1000
  • C:
  • Date of Birth:
  • India:
  • :
  • single:
Professional Summary

Proficient Clinical Documentation Specialist knowledgeable in evaluating medical records to determine accuracy and overall care quality. Talented professional with background in medical terminology, coding and team collaboration.

  • Documentation compliance
  • Medical terminology
  • DRG assignment
  • 3M Encoder
  • Records review
  • Relationship development
  • Intravenous Therapy
  • Chronic Disease Management
  • Precepting
  • Preventative Health
  • Infection Control and Aseptic Procedures
  • Triaging
  • Acute Care Expertise
  • Infection Control Measures
  • Personal Care Needs
Work History
Clinical Documentation Specialist, 03/2016 to 02/2020
Northwestern Medicine Lemont, IL,
  • Managed electronic clinical documentation and uploaded changes or updates using Epic.
  • Maintained strong knowledge of medical terminology, diseases and conditions and procedures.
  • Carefully reviewed patient files for clarity on diseases, diagnoses and procedures to determine quality of care.
  • Communicated with healthcare staff, including physicians, nurses and other caregivers to explain importance of accurate and clear documentation.
  • Questioned physicians regarding missing or unclear health record documentation and requested further information for clarification purposes.
  • Utilized Epic to manage and confirm patient data, such as insurance, demographic and medical history information.
  • Reviewed charts and flagged incomplete or inaccurate information.
  • Maintained accuracy, completeness and security for medical records and health information.
  • Drove operational improvements which resulted in savings and improved profit margins.
  • Maintained excellent attendance record, consistently arriving to work on time.
Float Registered Nurse, 10/2013 to 03/2016
Cvs Health Florissant, MO,
  • Collected blood, tissue and other laboratory specimens and prepared for lab testing.
  • Vaccinated patients to protect individuals from measles, pneumonia, influenza and other illnesses of concern.
  • Cared for patients in 25-bed critical access hospital, supporting fellow nurses in delivering outstanding treatment to patients.
  • Administered medications and treatment to patients and monitored responses while working with healthcare teams to adjust care plans.
  • Followed all personal and health data procedures to effectively comply with HIPAA laws and prevent information breaches.
  • Reported patients' status and delegated nurse assignments to achieve optimal outcomes.
  • Monitored patient reactions after administering medications and IV therapies.
  • Explained course of care and medications, including side effects to patients and caregivers in easy-to-understand terms.
  • Conducted ongoing monitoring and evaluations of behaviors and conditions, and updated clinical supervisors with current information.
  • Strengthened training and nursing knowledge by taking part in continuing education programs and workshops.
  • Offered exceptional care and support to individuals recovering from acute incidents and dealing with chronic conditions.
  • Managed patients recovering from medical or surgical procedures, including facilitating wound care, ostomy care, pressure ulcer prevention and pain management.
  • Communicated with healthcare team members to plan, implement and enhance treatment strategies.
  • Provided direct patient care, stabilized patients and determined next course of action.
  • Educated patients and answered questions about health condition, prognosis and treatment.
  • Collaborated with physicians to quickly assess patients and deliver appropriate treatment while managing rapidly changing conditions.
Staff RN Icu/Registered Nurse, PCU, 05/2013 to 03/2016
Kaiser Permanente Westside City, STATE,
  • Worked within interdisciplinary health care team to develop, implement and make adjustments to patient care plans, individualizing strategies and methods to improve health and meet recovery goals.
  • Conferred with physicians to discuss diagnoses and devise well-coordinated treatment approaches.
  • Delivered medications via oral, IV and intramuscular injections, monitoring responses to address new concerns.
  • Trained new nurses in proper techniques, care standards, operational procedures and safety protocols to optimize performance and safety.
  • Assessed medical status of patients pre and post-operation by checking vital parameters and supervising food intake.
  • Informed patients and families of effective treatment options and at-home care strategies, enhancing long-term outcomes.
  • Coordinated with physicians to perform bedside procedures such as intravenous injections, vascular line insertions and bronchoscopies.
  • Identified patient care requirements by establishing personal rapport with patients and families.
  • Monitored patients' conditions and reported changes in physical ability, appearance and behavior to discuss treatment with physicians.
  • Orchestrated quality-driven, cost-effective care for as many as 4 patients each day in high-volume ICU/PCU setting.
  • Updated patient charts using Epic with data such as medications to keep records current and support accurate treatments.
  • Observed and reported patient condition, progress and medication side effects to accurately document updates.
  • Educated patients and answered questions about health condition, prognosis and treatment.
  • Implemented interventions, including medication and IV administration, catheter insertion and airway management.
  • Collected blood, tissue and other laboratory specimens and prepared for lab testing.
Bachelor of Arts: Communication Studies, Expected in 12/1987
Sacramento State University California - Sacramento, CA,
Associate of Science: Nursing, Expected in 05/1990
Sierra College - Rocklin, CA

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Resume Overview

School Attended
  • Sacramento State University California
  • Sierra College
Job Titles Held:
  • Clinical Documentation Specialist
  • Float Registered Nurse
  • Staff RN Icu/Registered Nurse, PCU
  • Bachelor of Arts
  • Associate of Science