Medical Data Entry
Resume:
Summary
Skills
Experience
SIDRA NAYAB MD
**** ******** ***, ***** *** York 10469
Home: 646-***-****
*****.****@*****.***
To obtain a remote clinical documentation specialist position where my skills and qualification can be utilized to achieve maximum productivity. Highly knowledgeable and experienced Clinical Documentation Specialist has strong analytical and critical thinking abilities and the understanding of documentation standards in the medical field.Electronic Medical Record (EMR) of patient charts with Meditech, Epic .Has a Doctor of Medicine (M.D.) degree as FMG and Bachelor of Science in Biology degree from New York. I have on site and remote experience as a Clinical Documentation Specialist with more than five years of experience. Microsoft Word, PowerPoint,Excel
DRG methodology
Medical terminology
J.A. Thomas
Proficient in streamline, Meditech, EPIC
3M 360
3M CDIS
3M HDM
Optum
Cerner
ICD-9 and ICD-10
Confidential case documentation
Diagnostic tools
Strong clinical judgment
CDS July 2017 to January 2019
CLINICAL DOCUMENTATION SPECIALIST
Stamford Hospital, CT
Documented clinical details of patients' health conditions, diagnoses, and progress. Experienced with use and implementation/support of EMRs (3M 360, 3M CDIS, 3M HDM) and other clinical systems.
Reviewed CDI of patient medical record and data entry of patient charts,Optum,Cerner results in medical record.
Knowledge of regulatory Electronic Medical Record (EMR) environment especially in Emergency department, also has Surgery (Vascular, General, Gastro, Traumatic, urology) with Streamline Healthcare solution and attest supporting documents. Reviewed all concurrent medical record for compliance including completeness and accuracy for severity of illness (SOI) and quality using the Compliant Documentation Management Program (CDMP) documentation strategies.
Trained all members of the patient care team concurrent and retrospective interventions and interactions with, as well as the provision of education to physicians, residents, and other licensed independent practitioners.
Confirmed accurate completion of forms/reports for the admission, transfer and/or discharge of each resident.
CDS May 2016 to May 2017
CLINICAL DOCUMENTATION SPECIALIST
St. Vincent Hospital, CT
Served as a clinical liaison in teaching hospital clinical staff and coding staff by educating clinical staff of compliant documentation and accurate coding process in attaining the appropriate Diagnosis Related Groups (DRG).
Created and implement training and development for nursing staff, physicians and mid- level practitioners that addresses documentation issues & variances. Education and Training
Performed on-site or electronic coding 3M 360, 3M CDIS, 3M HDM. Clinical validation audits and interpretation of medical documentation to ensure capture of all relevant coding. Assessed data for relative complexity and projected mortality rates dependent on conditions. Ensured all relevant information pertaining of patient care is documented in Electronic Medical Record
(EMR) in teaching hospital department (ED, NICU,SICU,TICU,CCU,IR). CDI July 2014 to April 2016
CLINICAL DOCUMENTATION IMPROVEMENT SPECIALIST
Saint FrancisHospital Hartford, Connecticut
Developed personal responsibility for professional growth, development and continuing education to maintain a high level of proficiency.
Trained all members of the patient care team about documentation guidelines for medical records. Analyzed data and prepared reports quickly and accurately with Cerner Powercharts, Optum 360, 3M 360,JATA, Meditech.
Prioritized multiple tasks met all deadlines and maintained productivity standards. Reviewed and evaluated pediatric records for completeness and accuracy of information. Assessed data for relative complexity and projected mortality rates dependent on conditions. All Saints University School of Medicine 2014
M.D.
Dominica
Walden University 2011
Master of Public Health
Minnesota City, MN
City College New York (CCNY) 2010
Bachelor of Science: Biology
New York, NY
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