Clinical Documentation Specialist Resume Guide

Proficient clinical documentation specialist with experience in a variety of medical settings. Skilled at accurately and efficiently transferring data from patient charts into the correct electronic health record (EHR) system. Utilizes excellent knowledge of healthcare regulations to ensure compliance when managing clinical documents. Successfully increased accuracy rate for charting by 10% at XYZ Hospital, resulting in improved overall quality ratings.

Committed and detail-oriented clinical documentation specialist with 5+ years of experience in healthcare. Skilled at quickly deciphering complex medical terminology and accurately translating into patient records for review by doctors, nurses, and insurance providers. Proven track record of maintaining HIPAA compliance while improving document accuracy rates from 76% to 95%. Seeking an opportunity to utilize my expertise at ABC Medical Center.

Skilled Clinical Documentation Specialist with 7+ years of experience in healthcare settings. Displays a strong understanding of EHR systems, ICD-10 coding and medical terminology. Proven track record of improving processes that increase accuracy, efficiency and patient satisfaction. Seeking to join ABC Hospital as the next Clinical Documentation Specialist where my skills can be used to ensure accurate documentation for all patients.

Talented clinical documentation specialist with 5+ years of experience in healthcare. Experience includes analyzing and abstracting medical records to ensure accuracy, completeness, and compliance with applicable regulations. At XYZ Hospital I improved turnaround times by 30% while reducing errors by 40%. Skilled at training new staff on proper documentation processes and developing efficient workflows for improving efficiency.

Determined clinical documentation specialist with 7+ years of experience in the healthcare sector. Skilled at utilizing ICD-10 and CPT coding systems to ensure accuracy in medical records. Successfully implemented an automated system for more efficient processing of patient information, resulting in a 15% decrease in paperwork errors. Seeking to bring this expertise to ABC Health as part of their clinical documentation team.

Diligent clinical documentation specialist with 7+ years of experience in healthcare IT. Specializes in creating, editing, and validating patient medical records to ensure accuracy and compliance with HIPAA regulations. At XYZ hospital, led the implementation of an EHR system that reduced manual errors by 60%. Received multiple awards for exemplary service from clients across various organizations.

Amicable and detail-oriented clinical documentation specialist with 8+ years of experience in medical record review and analysis, patient care coordination and coding. At ABC Medical Centre, achieved a 95% accuracy rate for code assignment. Seeking to join XYZ Hospital as the next Clinical Documentation Specialist to provide high quality healthcare services while maintaining compliance standards.

Accomplished Clinical Documentation Specialist with 5+ years of experience in medical coding, documentation improvement, and quality assurance. Possess a deep understanding of ICD-10 and CPT codes for accurate diagnosis reporting. At XYZ Hospital successfully implemented hospital wide electronic health records system which improved patient care delivery by 50%.

• Mentored and trained 5 new clinical documentation specialists on coding, diagnosis and procedure validation requirements; reduced errors in medical records by 25%.
• Efficiently reviewed an average of 100+ patient charts per day for accuracy, completeness and compliance with regulatory guidelines while meeting established deadlines.
• Analyzed clinical data to identify potential inaccuracies or inconsistencies in documentation; successfully resolved 98% of discrepancies reported by healthcare providers within 24 hours.
• Streamlined processes used to audit patient files for quality assurance purposes, decreasing review time from 3 days to 1 day without compromising document integrity or accuracy levels.
• Reduced hospital readmissions rates related to incorrect coding issues by 10% through the implementation of a more efficient chart-auditing system utilizing specialized software programs.

• Prepared and reviewed 200+ clinical documentation for accuracy and compliance with the standards of care in a timely manner, enabling efficient billing practices that increased revenue by $4,000.
• Spearheaded implementation of new processes to streamline review times; reduced average turnaround time by 25%.
• Improved communication between departments through effective collaboration with nurses, physicians and other clinicians to ensure accurate representation of patient data in medical records.
• Demonstrated strong technical abilities while utilizing advanced software programs such as Epic EHRs and Cerner Millenium to maintain up-to-date electronic health records (EHR) systems for over 1,500 patients per month without error or omission.
• Consistently met all deadlines related to preparing/reviewing high volumes of clinical documents within established timelines while maintaining strict confidentiality at all times.

• Evaluated and revised 350+ medical records for completeness and accuracy, leading to a 17% improvement in the overall documentation quality.
• Achieved 95% patient confidentiality compliance rate by ensuring that PHI was kept secure at all times; decreased data breach incidents by 25%.
• Monitored physician coding activities to ensure accurate clinical documentations were completed on time with 97% effectiveness; improved turnaround time from 13 days to 8 days per case.
• Developed an electronic health record system tailored specifically for the organization’s needs, resulting in increased efficiency of information sharing among healthcare providers.
• Competently handled complex queries related to insurance companies and other third parties while providing necessary support during their audits with 100% accuracy adherence rate within deadlines set forth.

• Confidently revised and updated medical records of 500+ patients daily, ensuring accuracy and completeness in accordance with all HIPAA regulations.
• Processed over 1,000 clinical documents per week; made critical updates to existing documentation as needed to ensure clarity and compliance with federal guidelines.
• Coordinated frequently with healthcare providers on patient care information along with physicians’ orders for treatment modifications or changes when necessary.
• Assisted the nursing staff by providing support throughout their shift including preparing patient charts prior to admissions & discharges from the hospital unit each day.
• Reduced backlog of pending documentations by 30% within 3 months through excellent prioritization skills & efficient workflow management techniques utilized during review processes.

• Advised over 200 medical professionals on all aspects of clinical documentation and coding, resulting in a 30% decrease in errors.
• Researched complex health records to ensure accuracy and completeness; detected over $1 million worth of discrepancies within the first 6 months of employment.
• Interpreted physician notes, lab results & diagnostic reports accurately while ensuring compliance with HIPAA regulations; decreased time spent per document by 20%.
• Diligently reviewed patient charts for any missing information or incorrect codes prior to final submission, leading to an increase in revenue collection by 10%.
• Updated electronic systems daily with new patient data such as diagnosis codes & treatments provided for accurate billing processes that resulted in 90% fewer claims being denied reimbursement from insurers/payers.

• Reliably documented patient data in electronic health records (EHRs) and paper charts, ensuring accuracy and completeness of over 500 medical reports per month.
• Structured clinical documentation to meet payer requirements while adhering to departmental policies; increased reimbursement rates by 10% on average within the first 6 months of employment.
• Formulated comprehensive discharge summaries for 50+ patients weekly based on complex laboratory results & doctor notes, resulting in improved care coordination between healthcare providers & reduced readmission instances by 20%.
• Introduced novel coding methods that facilitated faster encoding turnaround times from 16 hours down to 8 hours; saved up to $10K in operational costs during a 3-month period without compromising overall quality assurance standards or workflow efficiency levels.
• Assessed gaps in existing documentation processes and implemented proactive measures such as developing quick reference guides and providing one-on-one training sessions which led to an increase of 23% team productivity across all departments involved with EHR management activities.

• Participated in monthly Coding Roundtables to discuss coding initiatives and collaborated with interdisciplinary teams to improve accuracy of medical records.
• Reviewed over 600 medical documents daily for completeness, accuracy, and compliance; achieved a 99%+ accurate documentation rate in the first quarter alone.
• Optimized clinical documentation by integrating ICD-10 codes into patient charts; resulted in an overall improvement in code capture rate of 10%.
• Coded more than 100 surgical reports accurately within 8 hours on average, utilizing extensive knowledge of anatomy & physiology as well as proficient use of 3M Encoder Pro software system.
• Accurately entered diagnosis data into electronic health record systems while auditing claims documents for accuracy prior to submitting them for reimbursement processing; reduced claim denials by 25%.

Bachelor of Science in Health Information Management
Educational Institution XYZ
Nov 2011

Certified Clinical Documentation Specialist (CCDS)
American Health Information Management
May 2017