Rn-clinical Resume Sample

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Willie Koch
902 McDermott Village,  Chicago, IL
+1 (555) 465 5661

Work Experience

Rn-clinical Documentation Specialist
05/2015 - PRESENT
Los Angeles, CA
  • Maintains positive relationships with referral sources, facilitates communication between referral sources, patient and family populations within assigned accounts, and attends professional organization meetings as approved. Maintains and follows patients while in the facility
  • Functions as a resource person
  • Experience and knowledge of State and Federal healthcare regulations in long term care
  • Knowledge of Medicaid reimbursement and coverage policies desired
  • Proficient use of applicable software programs, including Microsoft Office programs (specfically Excel and Word)
  • Manage multiple deadlines and prioritize assignments
  • Demonstrates expertise in performing comprehensive assessments utilizing expert knowledge base and experience to identify and manage and meet the needs of high-risk complex patients
  • Identifies assessment, diagnostic strategies, and therapeutic interventions within the plan that reflect current evidence, including data, research literature, and expert clinical knowledge
  • Includes the synthesis of patients’ values and beliefs regarding nursing and medical therapies
RN Clinical Ladder
12/2011 - 02/2015
Houston, TX
  • Identifies patient/family/community health care and education needs and collaborates in the development, implementation, and evaluation of teaching programs and materials that is appropriate to the patient’s developmental level, learning needs, readiness to learn and cultural values and beliefs
  • Shares expertise, particularly for complex patients, through the consultative process with all members of the health care team and provide recommendations that facilitate change
  • Synthesizes data, information, theoretical frameworks and evidence when providing consultation
  • Provides consultation to administrative, supervisory, and other health care staff in area of expertise to address health care issues
  • Assures that healthcare team efficiency and preferences are consistently addressed in implementing a multidisciplinary plan of care that involves the patient in decision-making and negotiating role responsibilities
  • Develops standards of care (via policies, procedures, protocols) to address the needs of focused patient populations utilizing evaluation analysis to recommend process or structural changes
  • Communicate face to face with individuals; communicate via call system with individuals; communicate via telephone with individuals; read, write, speak and understand the English language
RN Clinical Operations Consultant
09/2006 - 09/2011
Detroit, MI
  • Licensed Registered Nurse with an Indiana license
  • Understanding of health care claims, Current Procedural Terminology (CPT), International Classification of Disease (ICD), Healthcare Common Procedure Coding (HCPC) code sets
  • Experience and knowledge of State and Federal health care regulations
  • Proficient use of applicable technology, specifically Microsoft Office Applications (Excel and Word)
  • Not sanctioned or excluded from any program operated by federal or state agencies including Medicare and Medicaid
  • Proficient use of applicable software programs, including Microsoft Windows, Word, Excel
  • Train others; ability to maintain confidentiality; Analyze information, target trends; Compile data and statistics


Missouri State University - West Plains
2000 - 2005
Bachelor's Degree in Nursing

Professional Skills

  • Use fine motor skills to operate office equipment and/or machinery Ability to properly drive and operate a vehicle
  • Strong computer skills, including proficiency in word-processing, spreadsheet, and advanced computer applications (i.e. database and/or presentations)
  • Hospital inpatient nursing experience. Proven leadership and training experience in a hospital inpatient setting
  • Performs appropriate assessment of physical, social and psychological status (including cognitive, communicative and developmental skills as appropriate)
  • Diverse clinical experience with four or more years’ experience in a clinical or administrative setting
  • Prior experience using Electronic Medical Records (EMR), such as EPIC
  • Prior experience using the Microsoft Office Suite

How to write Rn-clinical Resume

Rn-clinical role is responsible for training, clinical, travel, reporting, database, radiology, health, leadership, technology, medical.
To write great resume for rn-clinical job, your resume must include:

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

Contact Information For Rn-clinical Resume

The section contact information is important in your rn-clinical 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 Rn-clinical Resume

The section work experience is an essential part of your rn-clinical 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 rn-clinical responsibilities. It's meant to present you as a wholesome candidate by showcasing your relevant accomplishments and should be tailored specifically to the particular rn-clinical position you're applying to. The work experience section should be the detailed summary of your latest 3 or 4 positions. Representative Rn-clinical resume experience can include:

  • Ensures the accuracy and completeness of clinical information used for measuring and reporting physician and facility outcomes (coding assignments, HAC, quality of care, facility and system initiatives) while facilitating HIMS dept compliance of time requirements for coding and billing revenue cycle
  • Educates customers and creates presentations and/or reports for clinicians and facility management on clinical documentation opportunities, coding and reimbursement issues, as well as performance improvement methodologies
  • Effectively and efficiently uses manpower, material and financial resources in accordance with hospital policies, and within established budget constraints
  • Fosters a culture of safety by assessing, applying appropriate interventions and evaluating the effectiveness of those outcomes
  • Knowledge and experience in detecting and investigating health insurance fraud, waste, and abuse
  • Creates a working environment that promotes positive employee attitudes, effective communications, collaboration, creativity, and continuous learning

Education on a Rn-clinical Resume

Make sure to make education a priority on your rn-clinical resume. If you’ve been working for a few years and have a few solid positions to show, put your education after your rn-clinical 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 Rn-clinical Resume

When listing skills on your rn-clinical 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 rn-clinical skills:

  • Serves as a role model in professional behavior, leadership skills and problem-solving ability, coaching, guidance, and interpersonal skills
  • Excellent communication skills including written and verbal, including ability to present to large or small groups
  • Utilizing all technology and resources effectively and efficiently
  • Demonstrates effective problem solving
  • Professional, positive demeanor. Problem solving and project management skills. Collegial work style; team-oriented
  • Associated business experience within the health care industry including experience with HEDIS / Stars

List of Typical Experience For a Rn-clinical Resume


Experience For Rn-clinical Documentation Specialist Resume

  • Prior experience advocating use of technology and workflow redesign in a clinical setting
  • Prior experience collaborating between information technology and clinical leadership
  • Nursing experience, preferably in the inpatient or post-acute setting, coordinating care across multiple disciplines as well as with providers
  • Organizes and prioritizes nursing care activities, considering the needs of the patient at the Clinician 2 level
  • Participates in the implementation and controls of cost-effective operating budget process in order to accomplish appropriate staffing levels.
  • Organizes, coordinates and prioritizes nursing care activities considering the needs of the patient at the RN Clinician 2 level
  • Demonstrates active support of the Journey to nursing excellence
  • Current Registered Nurse (RN) license in good standing

Experience For RN Clinical Lead Resume

  • Experience and knowledge of state and federal healthcare regulations, including reimbursement and coverage policies
  • Evaluates effectiveness of care, progressing patient towards desired outcomes at the Clinician 2 level
  • Evaluates effectiveness of care and care coordination progressing patients toward desired outcomes at the RN Clinician 2 level
  • Use hands and feet together for repetitive, coordinated motions with good hand-eye coordination
  • Extensive experience in a Cardiac Cath Lab or Critical Care; In depth knowledge of the management, education, and treatment of PAH patients
  • Manage customer/patient relationships with a focus on excellent quality and customer service
  • Extensive experience in a Cardiac Cath Lab or Critical Care

Experience For RN Clinical Team Manager Resume

  • Experience in quality improvement projects desired
  • Work in a team environment and manage multiple deadlines and prioritize assignments
  • Reviewing, analyzing, and reporting on quality discrepancies as reported through the call monitoring
  • Recommending and creating training opportunities to improve clinical best practice
  • Providing call monitoring training /calibration for associates
  • Ensuring team is meeting contractual obligations

Experience For RN Clinical Ladder Resume

  • Entering all call monitoring data into the quality tool on a daily basis, in order to determine causes of quality issues and to solve them
  • Coaching, counseling nurse to help drive clinical best practices
  • Participating in client meetings; prepares agenda and/or takes meeting notes
  • Translating and overseeing organizational strategies for assigned goals; analyzes progress of tactical issues
  • Working with 2 providers
  • Making recommendations for corrective and preventative actions as variation and performance gaps
  • Identifying client issues; receives and triages client requests
  • Maintaining positive rapport with clients

Experience For RN Clinical Leader Resume

  • Leading and participating in call calibrations to ensure credibility of the quality monitoring scoring process
  • Participating in trending activities that support the establishment of quality metrics, and continual process improvements across the organization
  • Providing management with daily, weekly, and month end quality results
  • Perform repetitive hand and wrist motion as well as using hands for gripping and squeezing
  • Current certification in Post anesthesia Nursing, Critical Care Nursing, or Ambulatory Perianesthesia nursing

Experience For Rn-clinical Specialist Resume

  • Normal hearing; normal vision, including color, night, and peripheral vision
  • Foster employee engagement, inspiring loyalty and leading by example
  • Stakeholder in determining appropriate OASIS scoring for correct home health reimbursement
  • Collaborates with leadership to audit and analyze performance trends in OASIS accuracy; assist in determining learning needs for clinical staff
  • Ensures timely processing of OASIS to meet CMS guidelines and CMS billing requirements
  • Assists Coding managers and internal auditors on external audit claims, assists with coding and documentation reviews and appeal letters as needed
  • Proactively identifying program issues and proposing ways in which to address their concerns
  • Proficient use of applicable software programs, including Microsoft Windows, Word, and Excel

Experience For RN Clinical Director MH Woodlands Surgery Center Resume

  • Responsible for the timely review and processing of Home Health OASIS admission document and Plan of Care
  • Knowledge of healthcare coding principles to include ICD-9, ICD-10, CPT, HCPCS, RUGS, and DRG
  • Proficient use of applicable software tools, including Microsoft Windows, Word, Excel, and Access
  • Accountable for regulatory and accrediting agency compliance standards on the unit
  • Clinical Certification in relevant practice area or Nursing Administration
  • Assists in coordinating the O.R. schedule

Experience For RN Clinical Quality Analyst Resume

  • Assists in cost management, including participation in product evaluation and inventory management, room turnover and utilizatio
  • Coordinates patient assignments and day to day nursing schedules for team RNs
  • Ensures that patient coverage is appropriately maintained on a 24 hour a day/7 days a week operating basis
  • Comprehend clinical policies and criteria to clearly articulate requirements surrounding health record information
  • A clean driving record is required, along with an active and unrestricted driver's license
  • Licensed Registered Nurse with a Georgia license
  • Follows physician’s orders, administers chemotherapy & patient medications & reconstitutes medications when needed. Adheres to six rights of medication administration as per policy
  • Coordinates and continuously monitors patient flow, supports patient throughout utilizing appropriate resources from admission, transfer or discharge and facilitates the processes in a timely manner

Experience For RN Clinical Operations Consultant Resume

  • Identifies clinical strengths & opportunities, re-assigns patient assignments to support clinical competency, coaches and mentors employees to improve performance and clinical outcomes
  • Flexes the employees to align with census fluctuations. Collaborates with the Operations Administrator, Nursing Manager, and Nursing Staff Office to meet hospital needs
  • Provides mentoring, coaching and performance feedback on an immediate basis to ensure the quality of nursing care
  • Assists in communication of hospital updates and Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Patient Perception Survey data
  • Fosters staff empowerment and open communication. Leads and guides staff to build a high performance and engaged team
  • Review medical records for various types of medical services for accuracy, completeness and consistency with professional standards and compliance with billing and coding requirements
  • Have understanding of healthcare claims, Current Procedural Terminology (CPT), International Classification of Disease (ICD), Healthcare Common Procedure Coding (HCPC) code sets

Experience For RN Clinical Reviewer Resume

  • Review medical record(s) for completeness, accuracy, consistency and clinical evidence for severity of illness (appropriate capture of true disease burden) and quality using official RA (Risk Assessment) and other relevant official documentation/coding guidelines
  • Consistent and effective use of Compliant Documentation Management Program® (CDMP) RA strategies
  • Effective and appropriate communication with physician/non-physician providers
  • Participate in RA steering committee meetings
  • Provide routine formal and informal (just-in-time) RA and documentation improvement education to providers/staff
  • Understand and communicate differences between Medicare Part A and B and RA payment methodologies [i.e., CMS Hierarchical Condition Categories (HCCs), RX HCCs, HHS HCCs, etc.] and how documentation impacts HCC capture and assignment (upon completion of training)

List of Typical Skills For a Rn-clinical Resume


Skills For Rn-clinical Documentation Specialist Resume

  • Recent clinical experience in a hospital setting, or 2 years recent clinical experience
  • Recent acute care experience in adult acute, critical care, or strong medical/surgical setting
  • Associated business experience within the health care industry including experience with HEDIS / Stars
  • Two years’ experience in home care agency or two years of supervisory experience in an acute or similar setting required
  • Current clinical experience, preferably in critical care or strong medical/surgical background
  • Strong clinical experience

Skills For RN Clinical Lead Resume

  • Billing and CPT coding experience
  • Previous experience influencing others resulting in changes in behavior (preferably with providers in various care delivery models)
  • Experience with discharge planning or coordinating patient care
  • Experience influencing others resulting in changes in behavior (preferably with providers in various care delivery models)
  • Knowledge and experience working and collaborating with clinical leaders
  • Routinely participates in patient care in the department to achieve cost and staffing effectiveness.
  • Experience in conducting evaluations and assessments, i.e. change readiness assessments,

Skills For RN Clinical Team Manager Resume

  • Five (5) years of recent experience as an RN in an acute care (hospital) setting, preferrably in Critical Care or the Emergency Department
  • Previous experience in provider-facing HEDIS strategy and education
  • Experience presenting education of HEDIS / Stars material to providers and provider office staff
  • Experience in provider-facing HEDIS strategy and education
  • If less than one (1) year experience in Level II or higher NICU, completion of NICU Didactic Training
  • Six months of experience working in oncology as a registered nurse required
  • Have accountability for the development of a strong team of A-player associates

Skills For RN Clinical Ladder Resume

  • Build a high performance team with strong emphasis on clinical accountability
  • Demonstrated leadership and teaching abilities
  • Establish a process to verify that skilled nursing and personal care services were provided; when requested by an AHCA employee
  • Four years of healthcare leadership experience
  • Demonstrated leadership, personal and professional ethics, and an ability to inspire and motivate others
  • Recent RN experience is desired for this role
  • Relevant experience or Master’s

Skills For RN Clinical Leader Resume

  • Experience as RN/LPN
  • Valid driver’s license and dependable transportation necessary
  • Clinical data abstraction experience
  • Properly drive and operate a vehicle
  • ICU and/or Critical Care experience

Skills For Rn-clinical Specialist Resume

  • Hospice or palliative care experience
  • IV related clinical experience
  • Demonstrates ability to supervise and direct professional and administrative personnel
  • Current State license, CPR certification and valid driver’s license
  • Licensed Registered Nurse obtained prior to hire date or job transfer date
  • Strong knowledge of the facility protocols and industry regulations is required
  • Acute inpatient hospital experience in the United States as a licensed RN
  • Improve patients’ clinical outcomes in a cost effective manner
  • At least one year of patient care experience required

Skills For RN Clinical Director MH Woodlands Surgery Center Resume

  • Med/surg experience: Required
  • Utilization review Management Experience
  • Strong work ethic built on a foundation of proactivity and teamwork
  • Rooming patients: Lifting and aiding patients as needed, extensive walking, on feet for majority of day
  • Understanding of Medicare, Medicaid and third party reimbursement methodologies

Skills For RN Clinical Quality Analyst Resume

  • Working knowledge of The Joint Commission, Centers for Medicare & Medicaid services (CMS) and VA guidelines on medical record functions
  • Receive and comprehend instructions verbally and/or in writing Ability to use logical reasoning for simple and complex problem solving
  • Communicates and educates patients and family members regarding critical medical information
  • Associates or Bachelors in Nursing
  • Energetic, self-motivated, engaging individual; ability to impact and influence employees at all organizational levels
  • Travel throughout central WV is required (provider visits - education and training)
  • Master’s of Science in Nursing
  • Divisional and unit specialized training

Skills For RN Clinical Operations Consultant Resume

  • Neonatal Resuscitation Program (NRP) training if applicable
  • LPS Certification and Credentialing within 90 days of eligibility (Psychiatry)
  • Triage: heavy phone work, sitting for majority of day
  • Active license to practice nursing in the State of Michigan
  • FIM credentialing for specified care areas such as follows: inpatient rehabilitation required within 6 months of hire or transfer
  • Committed to the practice of inquiry and listening
  • Seek as well as provides feedback for improved clinical practice

Skills For RN Clinical Reviewer Resume

  • Oversee day to day operations and human capital for defined program objectives and specified operational areas
  • Develop and implement clinical initiatives and programs
  • Assure compliance with mandated and corporate policies regarding other departmental areas such as nursing care coordination, medical management, utilization management and other care management activities
  • Develop team members and create department process flows for specified clinical programs and initiatives
  • Work closely with Medical Directors on program development and initiative implementations
  • Coordinates operation and systems within the unit on a specific shift

List of Typical Responsibilities For a Rn-clinical Resume


Responsibilities For Rn-clinical Documentation Specialist Resume

  • Learn/develop the skills necessary to perform CDMP
  • Prior experience in clinical program development and implementation, preferably in neurosciences or surgery
  • Advanced clinical nursing and/or critical care experience
  • Role or project-focused experience in leading cross-functional teams, performance improvement and/or program development
  • Creates and environment that supports and enhances service excellence and the Patient and Family Experience
  • Demonstrates ability to coach and mentor staff

Responsibilities For RN Clinical Lead Resume

  • Demonstrates proactive identification of problem areas and reports areas of concern to senior management
  • Facilitates staff competency by identifying, measuring and evaluating desired performance and holding staff accountable.
  • Utilizes training to guide physicians on documenting significance of any test results by identifying a diagnosis or condition
  • Keeps Coding Manager informed of potential and/or actual problems identified during the review process, concurrent progress and operation of program
  • Assists in cost management, including participation in product evaluation and inventory management, room turnover and utilization
  • Organizes documentation to meet physician, nursing and organizational policies and procedures
  • Works in a collaborative fashion with all providers in the acute care setting

Responsibilities For RN Clinical Team Manager Resume

  • Accurately interprets clinical information in the medical record, evaluating clinical indicators to identify potential diagnosis
  • Provides best-in-class customer service for our key strategic affiliates, including “white-glove” service for transfers, referrals, etc
  • Exceptional analytical, organizational, critical thinking, presentation, and facilitation abilities
  • Conducts provider on-site audits by researching provider clinical quality issues
  • Analyzes the assessment data to determine and make judgment to the nursing diagnoses or the issues (diagnosis)

Responsibilities For RN Clinical Ladder Resume

  • Implements the identified plan through coordination of care delivery, employing strategies to promote health and a safe environment (implementation)
  • Proficiency with Microsoft PowerPoint, EXCEL, Word, Outlook (scheduling)
  • Be knowledgeable on state & federal regulations that are applicable to agency; assist as needed with completion of initial and renewal home care licenses
  • Self-directed and motivated, with ability to work independently under general instructions
  • Successful completion of unit specific certifications (PALS, ACLS, TNCC, NRP, etc)
  • Monitors, evaluates, and reports postoperative organ function
  • Works in conjunction with the Business Office to coordinate financial aspects of transplantation/implantation for patients

Responsibilities For RN Clinical Leader Resume

  • Rotates Donor Call based on schedule assigned by Transplant Nurse Manager
  • Triages patient calls and referrals (PH position only)
  • Monitors, evaluates, and reports pulmonary function and identifies complications and interventions. (PH position only)
  • Conducts pre-delegation and annual assessment of delegate’s performance and processes to develop strategies for improvement
  • Collaborates with other departments and multiple patient care services such as Post-Anesthesia Care, Biomed, Facilities Engineering, and Anesthesia to facilitate case progression, and ensure special requirements and quality nursing care for the patient
  • Develops nursing policy and procedures in conjunction with education and training department. Assist with procedures, protocols and other related written resource materials appropriate specialties under nursing supervisor responsibilities.
  • Place needs of the patient first at all times. Care management and service delivery are developed with the goals of the patient’s healing and support in mind. Strive to deliver lasting value to our patients in the comfort of their home

Responsibilities For Rn-clinical Specialist Resume

  • Licensed RN in IL
  • Transcribes documentation clarifications as appropriate for SOI, Core Measures, and Patient Safety to ensure documentation compliance is accomplished
  • Effectively and appropriately communicates with physicians and other healthcare providers as necessary to ensure appropriate, accurate and complete clinical documentation. Communicates with HIM staff and collaborates with them to resolves discrepancies with DRG assignments and other coding issues
  • Participates in Task Force meetings, including feedback on outstanding issues, presentations for educational opportunities and any other needs identified by the CDI group
  • Teach, translate, and interpret patient satisfaction and voice of the customer data as a tool to enhance patients’ and families’ experiences
  • Partners and strategizes with senior executive and department leaders in improving clinical patient and family experience strategies; researches evidence-based best practices internally and externally, as well as manages projects for patient experience improvement initiatives
  • Serves as a consultant to assigned market region, consisting of multiple Florida Hospital Campuses. Partners with Analytics Improvement Strategist in creating strategies and forecasting performance for market region; campuses, service lines and departments

Responsibilities For RN Clinical Director MH Woodlands Surgery Center Resume

  • Performs clinical observations and assessments (audits) for all clinical departments and units, to assess best practices and opportunities for improvement. Write debrief report of findings; consult senior executives and department leaders on recommended cultural change to drive KPIs
  • Educates, supports and provides training to leadership, physicians and staff on the Florida Hospital Sequential Steps; clinical practices that provide a safe, efficient and effective care experience
  • Extracts, verifies, compiles, analyzes and formats clinical evidence-based best practices from leading Healthcare Systems and other healthcare industry sources for planning, decision making, and evaluation and accountability purposes
  • Collaborates with all FH campuses in training presentations and facilitating the patient and family experience culture curriculum. Including educating and orientating new and current staff to patient experience behaviors and standards
  • Consults and presents patient satisfaction results and findings using written and narrative descriptions, charts, graphs and tables, and/or presentation form to departments to assess patient experience strategies effectiveness
  • Leads change and develops relationships with hospital leaders and physicians to assist them in removing experience obstacles, coach and mentor them/their staff on behaviors

Responsibilities For RN Clinical Quality Analyst Resume

  • Organizes, coordinates and prioritizes nursing care activities considering the needs of the patient at the Clinician 2 level
  • Evaluates effectiveness of care and care coordination progressing patients toward desired outcomes at the Clinician 2 level
  • Implements patient population specific interventions based on individual patient needs at the Clinician 2 level
  • Develops and implements patient/caregiver teaching plan based on identified health education needs and the condition and age of the patient at the Clinician 2 level
  • 4 West is an 18 bed post-operative cardiac and thoracic acute care unit. Thoracic intermediate care unit is a 12 bed step down for cardiac and thoracic patients requiring a level of care between acute care and ICU
  • Extensive vascular procedure experience within a CVOR
  • Serves as physician extender in coordinating acute care workload for the physician

Responsibilities For RN Clinical Operations Consultant Resume

  • Completes nursing assessment on assigned physician workload
  • Assume responsibility for the professional development of self and contribute to and assist with the professional development of others
  • Maintains responsibility of competency and licensure requirements
  • Follows all professional practice standards, regulatory requirements and organizational policies and procedures, medical staff by-laws in the delivery of care
  • Facilitates the appropriate clinical documentation to ensure the intensity of services and level of acuity of the patient is accurately reflected in the medical record
  • Communicates appropriately and compliantly, either verbally, in writing, or by email with physician or care team to improve medical record documentation
  • Requests clinically credible documentation claifications as apporpirate for SOI, Core Measures, and Patient Safety as needed
  • Consistently identifies opportunities to improve clinical documentation
  • Participates in unit/organizational programs as needed

Responsibilities For RN Clinical Reviewer Resume

  • Provide education at weekly physician orientation, yearly resident orientation and other times as necessary
  • Maintains professional competency by keeping abreast of new coding issues and guideline. Attends classes and meetings as assigned. Reviews professional CDI and coding literature regularly
  • Works with RCO Coding staff, physicians and Patient Accounts with regards to payment denials, medical necessity and documentation issues. Instructs staff on proper documentation in the medical record
  • Collaborates with Coding staff, management and internal auditors during the CDI/Coding reconciliation process
  • Assists as needed on internal education documents with Inpatient coders
  • Collaborates with Performance Improvement & Safety on high risk cases to ensure that cases are properly documented, and coding staff is aware when specified diagnosis are identified
  • Utilizes grouping software to determine the working DRG

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