Clinical Documentation Improvement Resume Sample

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Gerardo Marquardt
605 Scottie Squares,  Houston, TX
+1 (555) 691 4412

Work Experience

Clinical Documentation Improvement Manager
11/2017 - PRESENT
San Francisco, CA
  • Adhering to the Association of Clinical Documentation Improvement Code of Ethics and American Health Information Management Association’s code of ethics related to query process
  • Building Trust – interacts with others in a way that gives them confidence in one’s intentions and those of the organization
  • Coding Technical Skills - regulatory coding (ICD-10-CM, ICD-10-PCS, ICD-9-CM, MS-DRGs, APR DRGs, POA Assignment) and associated reimbursement knowledge
  • Job Type: Health Care
  • Experience: At least 5 year(s)
  • Date Posted: 5/22/2018
  • Leading the monitoring of performance, collection and analysis of data to report on the effectiveness of process improvement
Clinical Documentation Improvement
11/2014 - 09/2017
Philadelphia, PA
  • Collecting and analyzing data to provide reports for HIM Department and hospital wide use and to make recommendations as appropriate
  • Assisting in the planning, development and implementation, and ongoing success of the CDI Program
  • Educating HIM CDI specialists, HIM coders, and members of the patient care team regarding documentation guidelines, including attending physicians, nursing, and other interdisciplinary team members
  • Personnel and Program Management
  • Hiring, orientation, and training CDI personnel
  • Leading and monitoring performance of CDI personnel
  • Evaluating performance and carrying out improvement activities
  • Educating internal staff, physicians, nursing, other interdisciplinary team members
Clinical Documentation Improvement Product Consultant
05/2011 - 05/2014
San Francisco, CA
  • Assists with initial & extended stay reviews as needed
  • Work closely with Physician Advisor, physicians, CM, and other related Hospital personnel
  • Collects and analyzes data to provide reports for HIM Dept and Hosp-wide use
  • Reports and discusses weekly/monthly performance
  • Conducts regularly scheduled staff meetings, and others as appropriate
  • Identifies trends and reports to HIM Director
  • Develop and coordinate education training programs regarding trends identified
  • Assists in the planning, development and implementation, and ongoing success of the CDI Program


Idaho State University - Twin Falls Center
2006 - 2011
School's Degree in Nursing

Professional Skills

  • Leads People. Implements and adapts managerial and staffing plans focused on the selection, retention, accountability and development of people so as to achieve Hospital and departmental goals and objectives
  • Strong speaking and writing skills required
  • Demonstrated quality improvement knowledge/skills with regard to workflow and productivity processes
  • Strong interpersonal communication skills with the ability to relate to all levels of education and organization positions
  • ​Excellent communication skills, oral and written
  • Work independently and as a member of a team utilizing critical thinking skills
  • RN with 5+ years of clinical experience working in an inpatient hospital, acute care setting OR a Medical Graduate with CDI experience

How to write Clinical Documentation Improvement Resume

Clinical Documentation Improvement role is responsible for events, health, database, training, integration, auditing, payroll, reporting, travel, software.
To write great resume for clinical documentation improvement job, your resume must include:

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

Contact Information For Clinical Documentation Improvement Resume

The section contact information is important in your clinical documentation improvement 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 Improvement Resume

The section work experience is an essential part of your clinical documentation improvement 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 improvement 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 improvement position you're applying to. The work experience section should be the detailed summary of your latest 3 or 4 positions.

Representative Clinical Documentation Improvement resume experience can include:

  • Maintains accurate records of review activities, ensuring reports and outcomes of CDI efforts are valid
  • Establishes and maintains effective working relationships as necessary to promote and support interdepartmental workflow
  • Follow up with physicians to get resolution of all queries prior to patient’s discharge in 85% of the cases
  • At least seven to ten years’ acute hospital clinical experience
  • Monitoring and reporting of quality and financial performance in collaboration with Strategic Services Associate (20%)
  • Suggests CDI and CAC product enhancement ideas based on subject matter expertise in CDI, hospital coding and billing

Education on a Clinical Documentation Improvement Resume

Make sure to make education a priority on your clinical documentation improvement 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 improvement 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 Improvement Resume

When listing skills on your clinical documentation improvement 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 improvement skills:

  • Experience in an acute care setting, including coding and management experience
  • Prior healthcare consulting experience
  • Knowledge, Skills, and Competencies
  • Prior management experience
  • Demonstrated effective, collegial communication with physicians and business office staff through direct discussion and written communications
  • Experience with encoders; experience with CAC software

List of Typical Experience For a Clinical Documentation Improvement Resume


Experience For Clinical Documentation Improvement Manager Resume

  • Maintain a clear working knowledge of the CDI application regarding data entry, report generation, and tracking methods
  • Manages the recruiting, hiring, and evaluation process of CDI staff
  • Act as Project Lead during engagements as required by management/practice
  • Participate in industry events and speaking engagements to promote CDI expertise and capabilities
  • Provides complete, accurate, and timely reporting of clinical documentation data metrics to leadership
  • Educates HIM CDI specialists, HIM coders, physicians, and other hospital staff prn
  • Collaborates with product management and the development team on the impact of long term trends related to CDI practices, new coding guidelines, quality reporting, pay - for - performance and new technology
  • Defines requirements for CDI, ICD - 9 - CM, ICD - 10 - CM, ICD - 10 - PCS, CPT and HCPCS code development for periodic releases of the LifeCode engine
  • Completes admission reviews and assigns a working Diagnosis Related Group. Ensures the working DRG and other information are entered in the Clinical Documentation Improvement database

Experience For Director of Clinical Documentation Improvement Resume

  • Initiates and maintains extensive interactions with physicians and mid-level providers to address the need for more detailed information in the medical record
  • Collaborates with healthcare professionals to ensure the severity of illness and level of services provided are accurately reflected in the medical record and to resolve physician queries and documentation issues prior to patient's discharge
  • Participate/lead evaluation/gap analysis of current clinical documentation improvement programs and provide written reports that describe our findings and recommendations for improvement
  • Leveraging previous CDI experience to participate in ongoing refinement of CDI assessment and implementation methodology and approach, including: development of deliverable templates, workflows, training manuals/content; integration with technology
  • Assist service offering leader with solution development and sales support of CDI through proposal development, responding to RFPs, development and delivery of client presentations
  • Engagement participation and overall quality assurance of deliverables as an individual and as an engagement team

Experience For Director Clinical Documentation Improvement Altamonte Springs Resume

  • Responsible for CDI program to initiate, influence, direct and oversee the clinical documentation improvement program activities to include productivity, quality, education and training, auditing, report management, performance improvement initiatives, and developing standardized practices, processes, policies and procedures
  • Accountable for the capture of appropriate clinical documentation for optimal quality and financial impacts for the acute care settings
  • Leads by example and promotes teamwork through a transparent, collaborative work environment
  • Cultivates positive, professional interdepartmental relationships with HIM director, coding team, case management, quality, and medical staff to support initiatives that advance business objectives
  • Collaborates with physicians and clinical leaders as an internal expert consultant to identify and implement improvements and standardization of documentation throughout CHRISTUS Health
  • Advocate for and facilitate the best practice model for CDI; linking the capture of documented bedside care to the most accurate administrative data reporting codes and acuity capture
  • Monitors the performance of each CDI program to ensure alignment and support of department and organization initiatives
  • Maintain staff knowledge and understanding in the ever-changing arenas of coding guidelines, DRG groups, case management/utilization review functions, clinical documentation trends, TJC standards, core measure guidelines, and clinical quality of care issues
  • Clearly communicate program updates, risks, or needs in a timely manner to the Vice President, Clinical/Business Operations Transformation and actively works to resolve and mitigate risk

Experience For Clinical Documentation Improvement Team Leader Resume

  • Identify and articulate project obstacles/ issues and determine potential solutions while working collaboratively
  • Communicates cooperatively as needed with coding specialists
  • Institutes coaching sessions or corrective action plans as necessary
  • Expresses self in a confident manner in individual and group settings
  • Assist with system-wide, regional and/or facility education programs, including presentations, program development, updated materials, and promotion of these programs
  • Serves as system functional lead related to ICD-10 transition for Clinical Documentation Improvement (CDI) Program

Experience For Director of the Clinical Documentation Improvement Resume

  • Assists Clinical Documentation Improvement Program Director with daily oversight of CDI team nurses at BWH and Brigham and Women’s Faulkner Hospitals
  • Assists CDI Program Director with performance evaluations, compiling monthly CDI nurse productivity metrics, and in identifying individual and team CDI continuing educational needs
  • Represents CDI Department on various committees
  • Oversight and management of department operations and personnel. (60%​)
  • Provides leadership for the operational unit on a daily basis
  • Ensures monthly metrics are kept on each staff member and determines root cause when metrics are not met

Experience For Clinical Documentation Improvement Director Resume

  • Interacts regularly with physicians, HIM and other ancillary departments to promote mission and vision of the Clinical Documentation program throughout Duke Health
  • Communication with Coding Manager and CDI Director of case and resolution (5%)
  • Directly responsible for all personnel action including, but not limited to, hiring, promotions, retention of staff, vacations, schedules, maintaining payroll records and time reports and terminations
  • Relevant clinical experience
  • Effective CDI program
  • 3M 360 experience
  • Identifies and records principal and secondary diagnoses, principal procedures and assigns a working DRG
  • Prepares, documents and conducts all performance evaluations

Experience For Manager Clinical Documentation Improvement Resume

  • Facilitation of issue identification and resolution of team conflict. Monitors Work Culture initiatives. Effective communication to team and to administration regarding any barriers to success identified within the CDI department
  • Maintenance of accurate records of review activities to comply with departmental and regulatory agency guidelines
  • Participation in the daily work load and function in the role of Clinical Documentation
  • Specialist, if deemed necessary by team staff shortage
  • Acts as an intermediary between physicians Enhances professional growth and coders
  • Effectively deals with resistance and conflict with members of the patient care team, physicians, Case Management and HIM through participation in educational programs in-service meetings, as appropriate
  • Uses personal judgment within broad guidelines to initiate review of inappropriate documentation by physicians Continually uses insight and follows-through to resolution, seeking support as needed feedback from the attending physician, department chair, Chief Medical Officer, or Chief of Staff

Experience For Clinical Documentation Improvement Consultant Resume

  • Assists with the utilization of monitoring tools others to track the progress of the DRG Assurance Program, interprets tracking information assess own performance, identify gaps between desired and reviews findings at regular meetings to facilitate communication with physicians, nurses, clinical care providers actual performance, and HIM coders
  • Collaborates in utilization management activities of patients being reviewed improve own performance
  • Aptitude in the use of computer applications, including MS Office (Word, Excel, PowerPoint)
  • Able to produce reports in Microsoft Office components, Word, Power Point, Excel, and Access data base
  • Broad knowledge of health care regulations. The ability to interpret, adapt, and apply guidelines and procedures, in addition to the ability to analyze complex clinical scenarios and apply critical thinking

Experience For Clinical Documentation Improvement & Utilization Management Specialist Resume

  • RHIA or RHIT credential from AHIMA. Preference given to RHIA
  • Physician documentation education
  • CDIP or CCDS certification
  • Communicate effectively with linguists and other CDI / coding product specialists to clarify development of CDI and diagnoses / procedures and sequencing
  • CPC, CPC - H, CCS, CCS - P, RHIT, or RHIA accreditation

Experience For Clinical Documentation Improvement Product Consultant Resume

  • BSN or equivalent required
  • As a Clinical Documentation Specialist
  • Travel and work across multiple sites as assigned
  • Work collaboratively in a matrixed leadership structure
  • License: RN, Nurse Practitioner (NP), MD, Physician Assistant (PA), RHIA/RHIT
  • CDI Specialist Certification through AHIMA or ACDIS

List of Typical Skills For a Clinical Documentation Improvement Resume


Skills For Clinical Documentation Improvement Manager Resume

  • Five (5) years of acute care hospital experience to include one (1) year of CDI experience required
  • Experience providing training to CDI Specialists
  • Experience providing CDI-based training to physicians and CDI Specialists
  • Direct experience in working as a CDI Specialist or in development of CDI program in the acute care
  • Hospital Coding experience desired
  • Clinical experience in acute care setting

Skills For Director of Clinical Documentation Improvement Resume

  • Experience with denials management and writing appeals
  • One (1) year of previous leadership experience, or verifiable management training is required
  • Demonstrated competence in data analysis and data interpretation
  • Experience with various health information systems, EHRs, grouper software
  • Prioritize workflow and manage various initiatives

Skills For Director Clinical Documentation Improvement Altamonte Springs Resume

  • CDI experience
  • Strong Technical Knowledge of: Healthcare domain and / or Hospital Encoder
  • Or more leadership experience required
  • Experience in chart audit
  • Experience with Case Management, Utilization Review
  • Coding and documentation audits, including presentation of audit findings and recommendations
  • Passing score (70%) on in-house CDS test
  • Working knowledge of CDI "best practices."

Skills For Clinical Documentation Improvement Team Leader Resume

  • A working knowledge of healthcare, CDI, billing companies, inpatient and outpatient hospital medical record coding and auditing
  • Proficiency coding/auditing inpatient and all outpatient acute care/facility record types
  • Knowledge base of ICD-9-CM coding and understanding of Diagnostic Related Groups (DRGs) required
  • Collaborates with the NLP (Natural Language Processing) team on CDI and hospital coding development
  • Provides detailed CDI and coding feedback on regression and functional tests using Windows based quality assurance software
  • Participates in division meetings, providing guidance and strategic direction on CDI issues
  • Work with HIM and CDI on month end close process to ensure accuracy of interim Coding on unbilled accounts
  • Compliance and reimbursement for various payers including Medicare and DRG based managed care
  • Physician training and education

Skills For Director of the Clinical Documentation Improvement Resume

  • Certified Coding Specialist - CCS, CCDS or CDIP is required
  • Travel out of town on a weekly basis M-F or work remotely from home, depending on the assignment
  • Current Nursing License in Illinois
  • Work in a fast-paced, rapidly changing environment with established time constraints and in a difficult situations
  • Flexible hours, according to program needs

Skills For Clinical Documentation Improvement Director Resume

  • Graduate from a Nursing program, BSN or graduate of Health Information Management RHIT, RHIA knowledge of HCC's
  • Interim HIM or Coding management
  • Coder education and training
  • Acts as a resource for CDI and coding questions and related issues internally
  • Share job opportunities through Social Media or email
  • Maintains up-to-date working knowledge of Medicare/Medicaid rules and regulations regarding CDI, POA, basic coding, as well as current trends and developments in the area of Clinical Documentation Improvement
  • Intervenes with facility CDI programs to address and resolve issues related to facility CDI process
  • Facilitates the development and review of division/facility CDI plans to ensure compliance with internal audits, state and federal regulatory requirements
  • Monitor productivity of CDI staff and coverage rates

Skills For Manager Clinical Documentation Improvement Resume

  • Work with Physician Advisors to address outlier physicians
  • Perform chart reviews to ensure appropriate documentation
  • Monitor and address low physician response and agree rates to queries
  • Work with HIM and hospital on delinquent queries
  • Operates the Business.Personally, and in collaboration with the departmental management team, directs the day-to-day activities of the CDI program and Hospital through policies, procedures, protocols, processes, goals, and objectives. Such activities shall result in

Skills For Clinical Documentation Improvement Consultant Resume

  • Compliance with regulatory requirements
  • Changes. Innovates, improves, and problem solves to further the goals of the department and Hospital
  • Responsible for personal professional growth
  • Provides management oversight of the daily operations of the clinical documentation program at assigned sites
  • Facilitates performance improvement activities for the clinical documentation management program
  • Serves as internal consultant on clinical documentation opportunities
  • Live in the West / Southwest with easy access to a large airport
  • Educate internal staff on clinical documentation needs, changes to clinical documentation guidelines, coding and reimbursement issues and conduct follow up reviews of clinical documentation to ensure points clarified with the physician have been recorded in the patient’s record

Skills For Clinical Documentation Improvement & Utilization Management Specialist Resume

  • Demonstrates clearly and effectively Optum’s Enterprise Computer Assisted Coding (CAC) application (hospital and professional), Coding Reimbursement Module and / or Clinical
  • Integrates Cleveland Clinic’s Improvement Model (CCIM) and tools into daily operations to drive best practices and outcomes (i.e. huddles, visual management tools, 4-blocker, return to green plan, A3, etc.)
  • Weekly monitoring and management of all CDISs interventions/coverage rates/physician response and agreement to queries
  • Complete annual performance reviews for employees and ensure that they receive timely feedback and performance/quality and training issues as appropriate
  • Ensure CDISs across Piedmont Healthcare are compliant with established policies, processes, and quality assurance programs

Skills For Clinical Documentation Improvement Product Consultant Resume

  • Complete disciplinary action as required
  • Initiate & participate in formal and informal, required and voluntary continuing education opportunities; enhancing professional growth, maintaining CEU’s required for licensure and/or certification, and enabling adherence to changes in regulatory requirements
  • Understand care delivery documentation systems and related medical record documentation of patient’s care reflective of the severity of the patient’s condition
  • Documentation Improvement team to ensure succession planning. Responsibility includes one manager who is directly responsible for and supports a total of 40 FTE’s. Manage department labor tracking and budget in accordance with organizational policies and in conjunction with AVP
  • Coordinates compliance initiatives
  • Knowledge of both ICD-9 and ICD-10

List of Typical Responsibilities For a Clinical Documentation Improvement Resume


Responsibilities For Clinical Documentation Improvement Manager Resume

  • Normal or corrected vision to normal range
  • Able to clearly communicate by phone or in person
  • RHIA, RHIT and/or CCS required
  • Knowledgeable of ICD-10 concepts and codes
  • Able to interact positively with physicians and staff, and understand their needs in the respective areas of healthcare
  • In-depth conceptual and practical knowledge in CDI required
  • CDIP, CCDS, or CCS credential
  • Date Posted: 8/9/2018
  • Strategically Supports. Analyzes operational and financial events and develops sound, workable solutions in response to Hospital needs. Uses communication and teaching skills, to improve the operational and financial condition and to enhance the financial understanding of others throughout the organization. Collaborates with others on projects and objectives

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