Review of medical records to facilitate the accurate representation of the severity of illness by improvingthe quality of physician's clinical documentation.Interacted with physicians and other members of patient's Interdisciplinary Care Team to support severityof illness, expected risk of mortality and complexity of care provided to patients Manage extensive retrospective medical record review, interaction with Physicians, Coders, HIMprofessionals, and Nursing staffActive participation in team meetings and education of staff in the CDI processDaily rounding with Physicians and the Healthcare team Concurrent initial and follow-up reviews of patients chart to improve quality, accuracy, and completeness ofmedical recordsProviding patient specific queries to physicians to improve documentation to identify additionalcomplications and related diagnosisCommunicating with physicians and key health providers and providing education regardingdocumentation and data required for accurate codingConcurrent and Retrospective review of medical records, advanced medical coding, assisting andfacilitating Physicians and middle-level care providers in the understanding and implementation ofhigh-quality clinical documentationIdentifying opportunities in coding and reimbursement issues, towards relevant quality and performanceimprovement Issuance of professionally relevant and compliant physician queries/clarifications,Assigning MS-DRGs, APR- DRGs, AP-DRGs,Significant accomplishments include greatly improved physician relationship and continuous physicianeducation towards achieving high-quality clinical documentation

Review of medical records to facilitate the accurate representation of the severity of illness by improvingthe quality of physician's clinical documentation.Interacted with physicians and other members of patient's Interdisciplinary Care Team to support severityof illness, expected risk of mortality and complexity of care provided to patients Manage extensive retrospective medical record review, interaction with Physicians, Coders, HIMprofessionals, and Nursing staffActive participation in team meetings and education of staff in the CDI processDaily rounding with Physicians and the Healthcare team Concurrent initial and follow-up reviews of patients chart to improve quality, accuracy, and completeness ofmedical recordsProviding patient specific queries to physicians to improve documentation to identify additionalcomplications and related diagnosisCommunicating with physicians and key health providers and providing education regardingdocumentation and data required for accurate codingConcurrent and Retrospective review of medical records, advanced medical coding, assisting andfacilitating Physicians and middle-level care providers in the understanding and implementation ofhigh-quality clinical documentationIdentifying opportunities in coding and reimbursement issues, towards relevant quality and performanceimprovement Issuance of professionally relevant and compliant physician queries/clarifications,Assigning MS-DRGs, APR- DRGs, AP-DRGs,Significant accomplishments include greatly improved physician relationship and continuous physicianeducation towards achieving high-quality clinical documentation

Clinical Documentation Improvement (CDI) Specialist 10/2012 to 09/2015Review of medical records to facilitate the accurate representation of the severity of illness by improving the quality of physician's clinical documentation.Interacted with physicians and other members of patient's Interdisciplinary Care Team to support severity of illness, expected risk of mortality and complexity of care provided to patientsActive participation in team meetings and education of staff in the CDI processConcurrent initial and follow-up reviews of patients’ chart to improve quality, accuracy, and completeness of medical recordsProviding patient specific queries to physicians to improve documentation to identify additional complications andrelated diagnosisCommunicating with physicians and key health providers and providing education regarding documentation and data required for accurate codingIdentifying opportunities in coding and reimbursement issues, towards relevant quality and performance improvementIssuance of professionally relevant and compliant physician queries/clarifications, Assigning MS-DRGs, APR- DRGs, AP-DRGs,Significant accomplishments include greatly improved physician relationship and continuous physician educationtowards achieving high-quality clinical documentation.

Collected and analyzed patient related medical information to develop diagnosis. Developed and provided effective treatment plans and family-based medical care services Prescribed and administered appropriate drugs and medicines to patients.Created and maintained proper and correct medical records, clinical reports and correspondence. Educated and counseled patients on healthy lifestyle, diet, and exercise routines.Directed and managed assigned team of medical personnel, efficiently.Collected and documented data related to patient illness, intensity of services and risk of mortality.Ensured proper documentation of discharge patients' diagnoses and co-existing complications to completely reflect the patient's clinical status and care. Identifies the need to clarify documentation in the medical record and initiates communication with physicians, physician assistants and nurses, by utilizing the appropriate Documentation Request tools in order to capture the documentation in the medical record that supports patient's severity of illness, risk of mortality and justifies the treatment providedDeveloped and implemented plans for both formal and informal education of physician, nursing, and other clinical staff.Identified strategies for changing work process to facilitate complete, accurate clinical documentation.Monitored and recorded information on Hospital Quality Measures in patients. Trained nurses and physicians on Hospital quality measures standards.Acted as inter-departmental Hospital Quality Measures liaison. Coordinated the development, maintained and monitored data quality.Analyzed Hospital Quality Measures compliance provided regular progress reports to Core Measure Team.