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Click here or scroll down to respond to this candidateCandidate's Name , IMDLincolnwood, ILSUMMARY Availability: 2 weeks Years of experience: CDI- 8 months Strengths: APR/DRG, MS-DRG, Auditing, Cardiac/Telemetry, General Med/Surg, General Surgery, ICU/CCU/NICU/PICU, Moms/Babies, Neuro/Neurosurgery, Orthopedic, Oncology, Pediatric, Palliative Care, PSI/HAC, Psych, Trauma, Urology, Vascular, Infectious diseases, Chest, Gynae/Obs Retro, 2nd level and Mortality Review experience Systems Experience: 3M Encoder, One Content, Paragon and Microsoft Office Products(Outlook, Word, Excel, PowerPoint, Microsoft 360 and Access) Environment: CommunityPROFESSIONAL EXPERIENCE12/2023-09/10/2024AGS Health, City, Washington, DCCDI Specialist-Remote (contracted to CHA Hollywood Presbyterian Hospital) Performing initial and concurrent reviews of medical records using my clinical knowledge to support an appropriate DRG representing the patient SOI and ROM Issuing queries to the appropriate physician to gather incomplete, missing, conflicting, or vague documentation Helping the physicians write an accurate diagnosis for the patient on each chart to help with both hospital billing and professional billing. Ensure accuracy and quality among medical coders, doctors, nurses, and other healthcare staff. Maintain charts, medical records, and reports and solve any issues involving documentation. Seek clarification by asking the medical team to provide clarification with written queries. Liaison between the medical staff and the coding department, striving to maintain the most accurate and complete medical record available for coding. Checking the patients medications and making sure they are correct for each diagnosis and if missing any and making sure if they are being administered correctly. Performs CDI DRG Reconciliation processes. Attend GMLOS to see where CDI can improve GMLOS with documentation. Provides recommendations to other CDI, Coding, and leadership because of process and documentation improvement opportunities. Check PSI and HCAP and any post-surgical diagnoses and determine whether its an expected outcome or complication. Review DRG Holds to see if the Coder missed any codes that could increase the DRG. This is reviewed in a Post Discharge state. Helping the physicians write an accurate diagnosis for the patient on each chart to help with both hospital billing and professional billing. Ensure accuracy and quality among medical coders, doctors, nurses, and other healthcare staff. Maintain charts, medical records, and reports and solve any issues involving documentation. Seek clarification by asking the medical team to provide clarification with written and verbal queries. Liaison between the medical staff and the coding department, striving to maintain the most accurate and complete medical record available for coding. Feb 2021 Mar 2021; Aug 2021 Sep 2021University of ArizonaObserver in Pathology Reviewed and analyzed pathology reports, identifying key documentation improvements to ensure accurate diagnosis coding and enhanced patient care records. Collaborated with pathology teams to improve the documentation of complex cases, ensuring that all clinical findings were accurately captured and reported. Participated in discussions on disease processes, contributing to the refinement of clinical documentation practices.July 2021 Aug 2021University of MiamiObserver in Pathology Assisted in the review and enhancement of clinical documentation within the pathology department, focusing on ensuring completeness and compliance with regulatory standards. Attended subspecialty pathology sessions to deepen understanding of documentation requirements across various medical disciplines. Contributed to the improvement of emergency case documentation, ensuring critical patient information was clearly and accurately recorded.June 2013 May 2018The Childrens Hospital, LahorePediatric post graduate Trainee Led efforts to improve the accuracy and completeness of pediatric patient documentation in high-stress environments, including neonatology, emergency, and ICU. Worked closely with healthcare teams to ensure that patient records accurately reflected the care provided, aiding in better clinical decision-making and patient outcomes. Conducted regular reviews of patient documentation to identify and correct inconsistencies, supporting improved quality of care.Jan 2011 June 2013University Medical and Dental College, LahoreLecturer in Medical Documentation Educated medical students on the importance of precise and thorough clinical documentation, including the use of medical terminology and coding systems. Developed and delivered curriculum focused on best practices in clinical documentation, helping to prepare future physicians for the challenges of accurate record-keeping. May 2009 Aug 2010Services Hospital, LahoreHouse Officer Managed comprehensive and detailed patient documentation in a high-volume ER setting, ensuring all procedures and patient interactions were accurately recorded. Worked with multidisciplinary teams to enhance documentation practices, leading to improved patient care and compliance with hospital standards. Regularly updated and reviewed patient records, ensuring they were complete and ready for subsequent care transitions.EDUCATIONPunjab Medical College, Faisalabad 2009 MBBS- Bachelor of Medicine, Bachelor of Surgery ECFMG Certified |
