Palm Medical Center
Register Nurse/Clinical Documentation Specialist/ MRA Specialist/RN Utilization Review
January 2016 — Present
• Reviews outpatient medical records throughout hospitalization. Analyzes clinical status of patient, current treatment plan and past medical history and identifies potential gaps in physician documentation.
• Communicates with attending physician to validate observations and appropriately prompts for documentation if necessary.
• Demonstrates basic knowledge of AHA Coding guidelines and applies to ongoing evaluation of the Identifies trends and/or opportunities to improve clinical documentation. Presents opportunities and potential solutions to the clinical documentation initiative team.
• Uses expert knowledge of software tools to appropriately query physicians for documentation
• Extensive knowledge of medical terminology, anatomy, physiology, pharmacology and disease processes.
• Identifies strategies for sustained work process changes that facilitate complete and accurate clinical documentation