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Clinical Documentation Manager Resume

Arlington, VA

SUMMARY:

Confidential is a successful Clinical Information Manager with 4+ years of hands - on expertise in the health care industry and highly familiar with Confidential and Centricity electronic medical record systems. He has helped organizations improve clinical documentation quality, significantly reduce medical coverage and payment denials from health insurance companies, increase patient volume, and increase patient satisfaction rates.

TECHNICAL SKILLS:

  • Microsoft (Word, PowerPoint, Excel, and Outlook), Microsoft Project, Microsoft SQL Server, and Microsoft Visio
  • Confidential Electronic Medical Record system
  • Centricity Electronic Medical Record systems
  • R (Programming Language)
  • Unified Modeling Language (UML)
  • GoToMeeting

PROFESSIONAL EXPERIENCE:

Confidential, Arlington, VA

Clinical Documentation Manager

Responsibilities:

  • Review electronic medical records for incomplete, ambiguous or conflicting health information to ensure that the medical record accurately captures patient condition(s), ensuring that the severity of illness and risk of mortality is maximized for patients.
  • Increased clinical documentation quality by greater than 95% by reviewing and ensuring that each section of an electronic medical record is accurate, complete, and meets the Meaningful Use requirements and Physician Quality Reporting System ( Confidential ) measures set by the Centers for Medicare & Medicaid Services (CMS).
  • Significantly reduced medical coverage denials for medical procedures, diagnostic imaging, and medications from Centers for Medicare & Medicaid Services (CMS) by greater than 90% by carefully reviewing and ensuring that each clinical documentation complies with Local Coverage Determinations ( Confidential ’s) criteria set by Centers for Medicare & Medicaid Services and various health insurance companies.
  • Reduced payment denials from various healthcare insurance companies by greater than 95% by reviewing and ensuring that the appropriate Current Procedural Terminology (CPT) codes and International Classification of Diseases 10 ( Confidential -10) codes are documented in each electronic medical record for billing office visits and medical procedures performed.
  • As a super user, Confidential trains health care providers and office staff on how to navigate and use Centricity Electronic Medical Record system to accomplish their daily job functions.

Confidential, Woodbridge, VA

Clinical Documentation Manager

Responsibilities:

  • Relieved physicians from the extensive clinical documentation in to Confidential Electronic Medical Record system allowing them to direct their undivided attention to their patients and provide optimal patient care leading to increased patient satisfaction rates.
  • Documented and ensured that each section of an electronic medical record which included patient’s history of the present illness, allergies, surgical history, personal/family medical history, medical procedures, review of systems, physical exam findings, reassessments, and consultations with other health care providers is complete and meets the Meaningful Use requirements and Physician Quality Reporting System ( Confidential ) measures set by the Centers for Medicare & Medicaid Services (CMS).
  • Assisted with writing physical medication prescriptions, various diagnostic test orders, referrals to specialists, laboratory tests, diagnostic or therapeutic radiological imaging orders, and sending E-prescriptions electronically to patient’s choice of pharmacy to prevent delay in office work flow and process.
  • Relayed critical lab value results from laboratory personnel to health care providers allowing the physician to take prompt actions in treating patients in extremely time sensitive circumstances.
  • As a super user, Confidential trained health care providers, medical staff, and new medical scribes on how to use and navigate Confidential Electronic Medical Record system.

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