Clinical Documentation Specialist Resume

[First Name] [Last Name]

Contact Address: [street] [Country] [City] [State/Province] [Zip Code]

Contact Number: (012)-345-6789

Email Address: [[email protected]]

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Career Objective:

To obtain a clinical documentation specialist position in ‘Prime Care Hospital’ and apply my experience and skills in reviewing patients’ medical records and creating clinical documents for insurance, legal and reference purpose.

Summary of Skills:

  • Licensed registered nurse with four years of experience in documenting clinical records
  • Knowledge of the state, federal, and local regulations implied on health care industry
  • Excellent computer and communication skills
  • Skilled in drafting clinical reports and presentations
  • Ability to maintain confidentiality of patients’ information
  • Strong interpersonal and team-building skills
  • Excellent manual dexterity with multitasking ability
  • Physically fit to carry 30 lbs, walk and stand for hours

Work Experience:

Clinical Documentation Specialist
Christ Memorial Hospital, New Haven, CT
March 2012 Present

  • Document clinical details of patients’ conditions, diagnoses, and progress
  • Ensure all relevant information pertaining of patient care is documented
  • Document CAT scans, EKGS, and blood sample results
  • Assist patients in submitting form for insurance
  • Participate in inter-departmental training
  • Review medical records and attest supporting documents
  • Answer queries of patients and medical staff
  • Gather, compile, and modify clinical documentation

Clinical Documentation Specialist
Central Health Care Center, New Haven, CT
June 2010 – February 2012

  • Ensured all medical records of the center is complete and accurate
  • Interacted with physicians and assigned ICD-9 CM codes
  • Evaluated documentation and communicated with physicians
  • Helped in improved documentation systems through research
  • Worked closely with nurses for documenting clinical information
  • Applying codes to medical records

Education:

  • Bachelor’s Degree in Nursing
    Angel’s Medical College, New Haven, CT
    2007
  • Associate Degree in Health Information Management
    Angel’s Medical College, New Haven, CT
    2009

References:

On request.

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