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Objective: To work as a clinical document specialist with physicians, clinicians and coders to review inpatient records while patients are still in facility and provide concurrent review for proper documentation.

Related Experience:

Confidential

CLINICAL DOCUMENTATION SPECIALIST
Responsibilities: To improve the overall quality completeness and accuracy of medical record documentation.
Initiating and following up on physician clarifications on daily basis for proper documentation. Working with coding staff to ensure proper DRG assignment and documentation guidelines. To communicate with physicians to ensure timely and accurate documentation. To continue to educate clinicians.

Confidential

clinical documentation specialist
Responsibilities: To review inpatient medical records to improve quality and completeness of Clinical
documentation on a concurrent basis using team process. To be a liaison between clinicians and coders with the ultimate goal of creating accurate and complete documentation. To provide education to the physicians as needed.

Confidential

clinical documentation specialist

Responsibilities: To review inpatient medical records for proper documentation. The review includes new

admissions as well as re-reviews every 2-3 days until the patient is discharged. To communicate with physicians to ensure timely and accurate documentation. To provide training and education to the physicians as needed. To communicate with coder for specific DRG assignment and documentation guidelines.

UTILIZATION MANAGEMENT

Responsibilities: To obtain information and complete cases in timely manner to avoid denials for payment. To

work with members of health care team, case management, social workers and nursing staff to assure all appropriate information is being communicated and delivered to or from the insurance companies.

Confidential

Responsibilities: Provide direct patient assessment and care Technical proficiency, application and performance of

all related critical care procedures and skills Utilizing knowledge of varied pharmaceutical agents and their usage within the ICU Utilization and application of varied patient monitoring systems including ventilators and invasive lines Assuring provision of patient quality care in compliance with hospital policy and procedures Collaborate with multi disciplinary health care team members to meet comprehensive care needs of patients.

Confidential

Staff Registered Nurse Medical-Surgical Intensive Care Unit

Patient profile: Medical, Surgical, Coronary Care, Acute Pulmonary and Substance abuse/overdose patients.

Responsibilities: Similar to the responsibilities at medical intensive care unit of Medical College of Georgia

Confidential

NURSING SUPERVISOR

Responsibilities: Monitor nursing and CNA staff members delegated assignments oversaw and evaluated technical

and clinical staff performance supervised direct patient care and ensure compliance with corporate policy and procedure oversaw staffing provide decisions regarding patient care and worked as a mentor for nurses and CNAs.

Confidential

Staff Registered Nurse Medical-Surgical Unit

Maintained ratio's 1:6-8
Patient profile: General Medical/Surgical, Infectious disease, Renal dialysis, Surgical GI, Pulmonary,

Gyn., Ortho, Neuro, Rehab, Palliative care

Responsibilities: Patient assessment and care Therapeutic communication and teaching with patients and

families Communication with doctors, case-managers, physical therapist and respiratory therapist Order entry and verification Medication administration Customer service.

Charge RN role: Function as staff Nurse and fulfilled Charge Nurse Duties delegated assignments for staff

Nurse and auxiliary workers supervised 3-6 co-workers oversaw and evaluated clinical and technical staff performance supervised direct patient care and ensure compliance with hospital policy and procedures.

Skills: Trilingual, English/ Hindi/ Gujarati write and speak fluently

Experience with MS windows 98, XP, Microsoft word, Excel

Excellent communication, interpersonal, organizational, problem solving, and leadership skills

Quick Study with ability to easily grasp and implement new ideas concepts and methodologies

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