Clinical Documentation Resume Sample

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Ollie Wintheiser
671 Obie Dale,  New York,  NY
+1 (555) 195 0786

Work Experience

Clinical Documentation DRG Specialist
12/2017 - PRESENT
Chicago, IL
  • Acts as the Reg’l coding contact person for the HIM Dept to support Edu & coding requirements
  • Develops & presents reports of audit results to Reg’l & facility staff & Sr Mgmt
  • Coding & Clinical Documentation Edu & Training: Supports the Reg’l coding & clinical documentation audit, Edu, & training needs of the region
  • Demonstrate knowledge of Official Coding Guidelines and the DRG Classification System to insure compliance with such regulations as they related to the CDI function
  • Direct/manage Division’s facility CDI teams
  • Employee Stock Options
  • PTO … and much more!
  • Able to work closely with the HIM coding staff to assure documentation of discharge diagnosis and any co-existing, co-morbidities that are a complete reflection of the patient’s clinical status and care
Clinical Documentation Spec
08/2014 - 10/2017
Los Angeles, CA
  • Educate internal staff on clinical documentation guidelines and conduct follow up reviews of clinical documentation to ensure points clarified with the physician have been recorded in the patient’s record. Reviews clinical issues with the coding staff to assign a working DRG
  • Uses software and CDI tools to conduct concurrent review to validate documentation adequacy. Queries physicians for clarification and specificity of documentation in accordance with hospital policy and the AHIMA Practice Brief: Developing a Physician Query Process. Consults with the Vice President of Medical Affairs when indicated by review results and/or query response
  • Coordinates final reporting of diagnoses with coding staff, providing clinical recommendations as needed
  • Performs admission and continued stay reviews using CDMP documentation guidelines to improve the overall quality and completeness of clinical documentation, and to ensure ordered procedures meet medical necessity guidelines.
  • Conducts follow-up reviews of clinical documentation at least every 48 hours or as indicated to ensure that points of clarification with the physician have been recorded in the patient’s chart
  • Runs reports as requested by Nurse Manager, CDS’s or Administration
  • Performs other tasks assigned, which are within the employee’s capabilities
  • Certified Coding Specialist Certification (CCS, CCS-P) required
Clinical & Documentation Review Consultant
08/2007 - 05/2014
Los Angeles, CA
  • Knowledge of 3M encoder
  • Manage the exchange of TMF documents with external service providers as applicable
  • Support the clinical study teams in ensuring regulatory documents are submission and audit ready
  • Liaise with functional team members to evaluate study-specific filing needs and aid in the development of study-specific procedures for managing and maintaining the TMF as applicable
  • Five (5) years recent clinical experience in a hospital setting, or four (4) years recent clinical experience and two (2) years ICD-9 Coding experience (optional)
  • Facilitates modification to clinical documentation supporting the clinical picture/level of severity rendered to all patients at the hospital for DRG based payers
  • Demonstrates strong organizational skills with demonstrated leadership ability
  • Possesses strong communication skills adaptable to a wide variety of interpersonal encounters with the entire hospital team
  • Demonstrates highly developed problem solving skills


Keiser University - Pembroke Pines Campus
2002 - 2006
Bachelor's Degree in Nursing

Professional Skills

  • Excellent critical thinking skills with the ability to quickly make decisive decisions from limited written and/or oral information; excellent reading comprehension
  • Proficiency in organizational skills and planning with an ability to juggle multiple priorities in a fast changing environment
  • Excellent communication skills to enable effective outcomes with the diverse complex clinical care teams
  • Excellence communication skills with ability to express oneself in writing and orally; and comfortable speaking in groups
  • ICD-10 coding knowledge with a strong understanding of the AHA Official ICD-10 Coding Guidelines and how to apply them
  • Proven capability in delivering and embedding new ways of working
  • Participate in and demonstrate an understanding of the Michigan Quality System/Continuous Quality Improvement and applies Lean Thinking concepts in daily work

How to write Clinical Documentation Resume

Clinical Documentation role is responsible for documentation, software, planning, medical, healthcare, reporting, training, database, auditing, security.
To write great resume for clinical documentation job, your resume must include:

  • Your contact information
  • Work experience
  • Education
  • Skill listing

Contact Information For Clinical Documentation Resume

The section contact information is important in your clinical documentation resume. The recruiter has to be able to contact you ASAP if they like to offer you the job. This is why you need to provide your:

  • First and last name
  • Email
  • Telephone number

Work Experience in Your Clinical Documentation Resume

The section work experience is an essential part of your clinical documentation resume. It’s the one thing the recruiter really cares about and pays the most attention to.
This section, however, is not just a list of your previous clinical documentation responsibilities. It's meant to present you as a wholesome candidate by showcasing your relevant accomplishments and should be tailored specifically to the particular clinical documentation position you're applying to. The work experience section should be the detailed summary of your latest 3 or 4 positions.

Representative Clinical Documentation resume experience can include:

  • Experience: 3 years recent RN experience required
  • Demonstrated good nurse-physician relationships in the past and has the ability to maintain those going forward
  • Highly organized and detail oriented, while also demonstrating the ability to synthesize information and demonstrate strategic thinking
  • Demonstrates adaptability and self-motivation by staying abreast of CMS rules and regulations and incorporating those changes into daily practice
  • Highly self-motivated, flexible, able to follow through in an ambiguous, fast-changing environment, and proven ability to meet deadlines under pressure
  • Related work experience (coding, patterns of care, clinical processes, etc.)

Education on a Clinical Documentation Resume

Make sure to make education a priority on your clinical documentation resume. If you’ve been working for a few years and have a few solid positions to show, put your education after your clinical documentation experience. For example, if you have a Ph.D in Neuroscience and a Master's in the same sphere, just list your Ph.D. Besides the doctorate, Master’s degrees go next, followed by Bachelor’s and finally, Associate’s degree.

Additional details to include:

  • School you graduated from
  • Major/ minor
  • Year of graduation
  • Location of school

These are the four additional pieces of information you should mention when listing your education on your resume.

Professional Skills in Clinical Documentation Resume

When listing skills on your clinical documentation resume, remember always to be honest about your level of ability. Include the Skills section after experience.

Present the most important skills in your resume, there's a list of typical clinical documentation skills:

  • Excellent verbal and written communication skills, analytical thinking and problem solving skills with attention to detail are required
  • Superior interpersonal skills, including the ability to establish and maintain good working relationships with peers, colleagues and management
  • Proficient in oral and written communication, excellent organizational skills and the ability to manage multiple tasks with great attention to detail
  • Solid line management experience, particularly leading global teams
  • Effectively communicates with users, at all levels of the clinical documentation build team
  • A demonstrated, deep understanding of the TMF Reference model and processing of documentation into the eTMF / CTMS system

List of Typical Experience For a Clinical Documentation Resume


Experience For Clinical Documentation Spec Resume

  • Remains current with clinical knowledge and documentation requirements. Attends education programs that pertain to specialty area being covered. Assumes responsibility for professional development
  • Advanced communication and interpersonal skills to work with all levels of internal and external customers. Excellent written and verbal communication, critical thinking, and creative problem solving. Ability to be diplomatic and negotiate, with strong conflict management skills
  • One (1) year experience as a Clinical Documentation Specialist (or similar role) in an acute care setting within the last 2 years required
  • Works closely with Care Site Chief Medical Officer and CDI Medical Directors to ensure effectiveness of CDI program
  • EPIC system experience
  • Abstract all required information in MiChart in a timely manner to assure accurate reporting of metrics
  • Self directed with the ability to work in a fast paced environment
  • Project a professional image that is consistent with the NCH value of Customer Focus

Experience For Clinical Documentation Liaison Resume

  • Perform initial and follow-up reviews of inpatient records within 24-48 hours of admission to clinically evaluate the opportunity to query the clinician for additional diagnoses and/ or procedures that impact SOI, ROM, POA and hospital reimbursement
  • Utilize the 3M/MiChart system to determine appropriate DRG, ICD-10 codes, SOI, ROM, and POA assignment
  • Evaluate clinical documentation such as signs, symptoms, lab results, diagnostic information and treatment plans to determine documentation improvement opportunities and appropriately query providers
  • Initiate communication with clinicians through the formal query process or during face-to-face discussions when there is missing, ambiguous, or conflicting documentation to ensure timely and accurate documentation at the point of care
  • Facilitate change processes required to capture needed documentation, such as redesign or enhancement of EHR data capture functionality and/or template redesign
  • Identify documentation trends to be shared with the clinical service and the HIM physician advisor to allow for clinician education
  • Prepare case specific documentation examples and power point presentations to be given to clinical treatment teams and departments
  • Maintains currency with work processes, tools, and clinical and administrative applications necessary to perform job functions

Experience For Clinical & Documentation Review Consultant Resume

  • Organize TMF files for pharma client
  • Track and manage eTMF system issues with the eTMF vendor and user community
  • Work with relevant parties to track and manage eTMF bulk updates
  • Works with CRO partners and / or Clinical Systems to prepare for and implement data (document) migrations
  • Highly proactive, flexible, curious and resilient

Experience For Sahs Clinical Documentation Spec A Resume

  • Proficient in Microsoft Applications; Word, Excel, Project, and PowerPoint
  • Travel (<10%)
  • Leads and coordinates the day-to-day activities of the Clinical Documentation Integrity (CDI) operations at the care sites. Oversee individual CDS workload/assignments and performance. Serves as a subject matter expert and resource for internal customers and Clinical Documentation Integrity Specialists (CDSs). Performs the work of staff
  • Assists in implementing new SCL Health policies and procedures related to CDI and coding guidelines. Accountable for dissemination of all facility-specific and CDI-specific information to CDSs and adherence of CDSs to requirements
  • Communicates issues or concerns with site CDI to CDI Manager
  • Arranges and delivers education for providers and care givers based on identified opportunities
  • Active RN license in good standing required. Current Certified Documentation Improvement (CDIP) or Certified Clinical Documentation Specialist (CCDS) within 1 year of hire/eligibility required

Experience For Clinical Documentation DRG Specialist Resume

  • Exhibits excellent customer service skills and behaviors toward internal and external customer and co-workers. Promotes positive public relations with patients/residents, family members, guests, and others
  • Supports, cooperates with and demonstrates safe work practices and attitudes, follows safety rules-including universal precautions-reports and prevent/corrects unsafe conditions and behaviors, and participates in organizational and departmental safety programs
  • Concurrent review/Query process: Based on review of the existing medical record, determines principal diagnosis, qualifying secondary diagnoses, impacting procedures and assigns appropriate working DRG
  • Queries and educates providers to obtain greatest possible diagnostic specificity, and present on admission status, to accurately reflect the patients condition
  • Adheres to industry standards pertaining to compliance
  • Provides clinical evaluation of the medical record to facilitate capture of comprehensive medical record information to reflect clinical treatment, decisions, and diagnoses for inpatients
  • Communicates with physicians and others to obtain appropriate information

Experience For Clinical Documentation Lead Resume

  • Provides or coordinates education to internal customers and acts as consultant to coders
  • Gather and analyze information pertinent to documentation findings and outcomes
  • Performs a thorough chart review to identify that all co-morbidities/complications are
  • Completes the DRG worksheet and reviews documentation of the medical record at a frequency determined by the accuracy and thoroughness of the documentation at last review and no less than every 7 days
  • Utilizes monitoring tools to track the progress of the DRG Assurance program, through interpretation of DRG tracking reports, monitoring reports and data. Able to identify areas of focus through report analysis
  • Maintains an expert level of knowledge of CDI related practice and performance

Experience For Temp-clinical Documentation Associate Resume

  • Knowledge of “Aware notes” used for documentation
  • Current TX RN license; current CPR certification by the American Heart Association
  • Close, distant, and color vision is required
  • The work environment is at a moderate noise level (business office with phones, copiers, computers, and printers)
  • CCDS, CDIP required to be attained within two years of date of hire/transfer
  • Reviews, escalates and assists in escalating unanswered queries to Physician Champion/CMO. Acts as a CDI liaison for other Care Site disciplines to facilitate coordination and collaboration as needed to achieve goals. Assists with quality assurance activities. Audits work of CDSs for accuracy, productivity and quality standards. Proactively identifies issues or trends, and proposes solutions

List of Typical Skills For a Clinical Documentation Resume


Skills For Clinical Documentation Spec Resume

  • Proficient organization and planning skills necessary to work independently and effectively manage time
  • Strong computer skills and willingness to learn computer applications relative to position
  • Demonstrated ability to work effectively with many different types of personalities at all levels of the organization
  • Excellent interpersonal, collaboration, change management, and stakeholder management skills
  • Critical care nursing experience
  • Experience in hospital Case Management with knowledge of or certification in Case Management, coding or related fields
  • Three to five years of inpatient coding experience is necessary for those with RHIT/RHIA credentials
  • Experience with Allscripts version 15
  • Three (3) or more years’ experience in CDI

Skills For Clinical Documentation Liaison Resume

  • Experience in acute care hospital
  • TMF experience is required
  • Clinical Studies experience is required
  • Valid Registered Nurse (RN) license in the State of Florida required
  • Demonstrates self-directed, motivated behavior
  • Demonstrates the ability to develop and maintain supportive, collaborative relationships with physicians, Case Managers, etc
  • Physical demands require standing, walking, sitting, lifting, carrying up to 25 pounds
  • Possess proactive, strategic, innovating and out-of-the-box thinking
  • Proficiency in computer use, including database and spreadsheet analysis, presentation program, word processing and internet search

Skills For Clinical & Documentation Review Consultant Resume

  • Supports timely, accurate and complete documentation of clinical information used for measuring and reporting physician and hospital outcome data
  • Develop and verify new tools (such as reports) for overseeing the TMF / CTMS and ensuring that quality, completeness and timeliness are met
  • Prepare technical training on proper use of the TMF and new functionality as necessary and its tools and provide training as needed to internal staff and CROs
  • Assist with planning and leading of Care Site meetings and CDS peer review activities. Participates in performance improvement/action plan activities
  • Produce reports using multi-formats and software i.e. Word, Excel
  • Work flexible work schedules to accommodate provider rounding schedules and required medical staff presentations
  • Familiarity with clinical trial processes and ICH/GCP guidance and working knowledge of essential documents

Skills For Sahs Clinical Documentation Spec A Resume

  • Provide support to clinicians on making addendums and SmartTexts and SmartPhrases in MiChart
  • Attention to Detail with thoroughness and accuracy when accomplishing a task
  • Able to build a project plan & business case (including costings and timelines) and lead a large cross-functional team to deliver technical/business solutions
  • Work independently, self-motivated and an ability to adapt to the changing healthcare environment
  • New York State Registered Nurse and/or certified coding specialist
  • Maintains CDI tools used in data tracking and analysis
  • Provide on-going education to all clinical treatment teams as it relates to documentation and the EHR
  • Participate in department/unit activities including, but not limited to, staff meetings and in-services
  • Participate in the testing and verification of new eTMF system functionality

Skills For Clinical Documentation DRG Specialist Resume

  • Extensive knowledge of disease processes and clinical outcomes
  • Plan and organize workflow in order to meet deadlines
  • Present data findings / report to medical staff committee's as needed
  • Establish cooperative working relationship with diverse groups and individuals, medical staff and other health care disciplines and interact with all levels of employees
  • Clinical knowledge with the ability to review documentation and determine what documentation is needed to provide accurate DRG, POA, SOI, and ROM scores
  • Write appropriate queries to the clinical care team in accordance with the AHIMA Query Policy
  • The Documentation Specialist is directly responsible to the Director of HIM. A collaborative relationship with other staff is maintained
  • Guides, supports and sponsors the Clinical Documentation Improvement Program efforts. In partnership with Clinical Coders, ensures patient classification and DRG assignment are supported by provider documentation and in compliance with rules, regulations and guidelines
  • Communicates with providers and healthcare team members to clarify documentation necessary for complete and accurate coding for proper reimbursement via verbal or electronic query practices

Skills For Clinical Documentation Lead Resume

  • Educates members of the healthcare team about clinical documentation guidelines, coding and quality measures via 1:1 rounding, unit rounds, presentations and providing documentation tips
  • Experience developing clinical documentation within Allscripts SCM, required
  • Experience within Health IT
  • Knowledge and experience with the use of TMF systems and associated business processes
  • Meets weekly, or as required, with the HIM Manager and the Vice President of Medical Affairs to address issues/concerns regarding documentation, education, etc

Skills For Temp-clinical Documentation Associate Resume

  • Policies & Procedures – articulate knowledge and understanding of organizational policies, procedures and systems
  • In depth understanding of anatomy, physiology, medical terminology, and disease processes required
  • Follows the Clinical Documentation configuration management process from idea, design, development, test, implementation and maintenance
  • Utilizes clinical expertise, clinical documentation improvement practices and facility specific tools for best practice and compliance with the mission and vision of the revenue cycle
  • Provides daily clinical evaluation of all documentation by the Medical Staff and healthcare team, lab results, diagnostic information and treatment plans to assure the appropriate clinical severity is captured for the level of service rendered

Skills For Allscripts Clinical Documentation Consultant Resume

  • Reviews and makes recommendations for improvement to the overall quality, integrity and completeness of clinical documentation by utilizing knowledge of DRG-based payor issues, clinical documentation guidelines, policies and procedures
  • Provides daily clinical evaluation of all documentation by the Medical Staff and healthcare team,lab results, diagnostic information and treatment plans to assure the appropriate clinical severity is captured for the level of service rendered
  • Number and Type of Employees Supervised: None
  • Licensure, Registry or Certification Required: Licensed as a registered nurse in South Carolina
  • Render Care to Patients of All Age Groups
  • Knowledgeable of Federal, State, and other payers’ regulations, requirements, and criteria
  • Knowledge of hospital and ambulatory clinician workflow and regulatory requirements
  • Advanced desktop computer hardware and software knowledge, required

Skills For Clinical Documentation Quality Coordinator Resume

  • Excellent working knowledge of International Conference on Harmonization/ Good Clinical Practice regulations and Corporate & R&D policies and Standard Operating Procedures for sponsor study records
  • Knowledge of Trial Master File Reference Model
  • In-depth knowledge of electronic document management applications (e.g., Documentum, SharePoint, Livelink)
  • Demonstrated track record in leading and effecting significant change, innovation and results in multiple major processes/projects/systems /policies which span multiple functional/specialist areas
  • Navigate the EHR to identify documents for review to provide accurate capture of clinical information
  • Licensure: Registered Nurse license (RN), Registered Health Information Administrator (RHIA), Registered Health Information Technician certification (RHIT), Certified Coding Specialist certification (CCS) required. Certified Professional Coder (CPC), or a combination there of

Skills For Clinical Documentation Integrity Specialist Resume

  • Knowledge of age-specific needs and the elements of disease processes and related procedures. Strong broad-based clinical knowledge and understanding of pathology/physiology of disease processes
  • Facilitates appropriate clinical documentation to ensure that the level of services and acuity of care are accurately reflected in the medical record to improve overall quality and completeness of clinical documentation
  • Communicates effectively (face-to-face) with Physicians, the Healthcare Team, and Multidisciplinary Teams to ensure accurate and complete documentation of all relevant diagnoses, procedures and treatments. Provides education on clinical documentation opportunities to support acuity, quality, and coding
  • Initiates Physician Queries for clarification and specificity as appropriate, following established query guidelines for compliant queries. Performs follow-ups to ensure clarification was documented prior to discharge
  • Performs follow-up reviews and updates CDI/DRG worksheet to reflect changes in patient status, to verify the most appropriate Prin Dx and DRG and validate supporting documentation
  • Works collaboratively with the Coding and Quality Teams to ensure the clinical documentation fills the 'gaps' between clinical and coding language
  • Works collaboratively with the Coding and Quality Teams to ensure the clinical documentation fills the gaps between clinical and coding language

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