clinical documentation specialist resume example with 5+ years of experience

(555) 432-1000,
, , 100 Montgomery St. 10th Floor
Professional Summary

Highly-trained, driven and committed Clinical Documentation Specialist with almost 2 years of experience in current role. Excellent reputation for exceeding documentation goals, taking initiative and improving documentation through close collaboration with clinical leadership and care teams. Proven excellence in ability to manage multiple tasks and work independently or as a collaborative team member. Aiming to utilize obtained knowledge and expertise in clinical documentation to help lead and assist fellow team members to continue to drive clinical excellence throughout various care teams at Oak Street Health.

  • In depth knowledge of medical conditions, terminology, medications, diagnostics and procedures
  • HCC ICD-10 codes and accurate and proper documentation practices
  • Tracking medical records and leveraging BB and payer data information
  • Navigating Canopy, Greenway and external EMRs
  • Great problem solving skills
  • Analytical and detail oriented
  • Excellent written and verbal communication skills
  • Easily adapt to rapidly changing environment
  • Confident in training skills
  • Team player
  • Self-management
  • Planning and executing
  • Energetic work attitude
  • Organized and goal oriented
  • MS office and Excel proficient
  • Fluent in Spanish
Walden University Minneapolis, MN, Expected in Master of Science : Healthcare Administration - GPA :

Minored in Leadership and Organizational Development

  • Graduated magna cum laude
  • Focused on health policies, regulations, technology, business and operational skills in healthcare field
Universidad Catolica Nordestana San Francisco De Macoris, Dominican Republic , Expected in M.D. : - GPA :
  • Graduated cum laude
University of Rhode Island Kingston, RI , Expected in Bachelor of Science : Biological Sciences, Spanish Language & Literature - GPA :
Work History
Bjc Healthcare - Clinical Documentation Specialist
Alton, IL, 11/2020 - Current
  • Carefully review patient's EMRs to identify potential suspects based on gathered patient data including labs, tests, images and patient visit notes.
  • Request patient records based on provided Blue Button and payer data.
  • Prepare and lead bi-weekly Rejected Suspect Reviews.
  • Communicate professionally and effectively with Senior Medical Directors and care teams regarding missing or unclear clinical documentation.
  • Assign accurate and specific HCC diagnosis codes based on review of patient's internal and external EMRs.
  • Supporting our cohort continuously by providing constructive feedback and participating in available pilot opportunities for improvements and new products.
  • Identify chronic condition trends based on patient demographics and current health conditions and highlight opportunities for clinical intervention.
  • Continuously meeting or exceeding weekly performance metrics by reviewing 100% of visits at least 24 hours prior to first visit and exceeding average of >1 suspects created per chart.
Ascension Health - Clinical Informatics Specialist
Warren, MI, 07/2019 - 11/2020
  • Accurately documented and recorded clinical visit encounters.
  • Properly documented patient history, diagnosis and procedures performed.
  • Provided support to clinical care teams in patient care coordination.
  • Processed referrals and order requests in an accurate and timely manner.
  • Assisted care teams with interpretation of population health data.
  • Reviewed patient charts and leveraged population health data and available resources to address any opportunities in patient care or documentation.
  • Effectively communicated and provided support to care teams as needed to ensure patient care needs were continuously met.
  • Assisted in floor training for new hires and provided support to colleagues and care teams as needed.
  • Successfully earned fifth star of Stars Criteria.
  • Implemented new strategies to help clinical teams improve medical record request tracking.
San Vincent De Paul Hospital - Medical Intern
City, STATE, 01/2013 - 01/2015
  • Assisted physician in providing care to patients including examinations, immunizations and any necessary diagnostics and treatment procedures.
  • Created documentation of patient visit encounters including patient history and clinical assessment and diagnosis.
  • Performed community outreach to underserved populations and served as advocate for vaccinations and control of infectious diseases.
  • As lead intern led and organized team of 18 other interns through assigned tasks and duties.

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Resume Overview

School Attended

  • Walden University
  • Universidad Catolica Nordestana
  • University of Rhode Island

Job Titles Held:

  • Clinical Documentation Specialist
  • Clinical Informatics Specialist
  • Medical Intern


  • Master of Science
  • M.D.
  • Bachelor of Science

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