Clinical Documentation Patient Care

Chiedu Dili Ogbechie, MD, CCDS

Rancho Cucamonga, CA 91730

Email: **********@*****.*** Tel: +1-909-***-****

PROFESSIONAL SUMMARY

Clinical Documentation Specialist with over 3 years of experience, specializing in optimizing clinical documentation for accuracy and compliance. Proficient in EMR systems like EPIC and Cerner, enhancing workflow efficiency and patient care quality through advanced analytical and coding skills. Committed to continuous education and training of healthcare professionals to uphold high standards in clinical documentation.

SKILLS

Trained Physician: Possess comprehensive knowledge of anatomy, physiology, disease processes, medical terminology, and pharmacology.

Coding Proficiency: Excellent understanding of CPT, ICD-10, and CMS standards, with the ability to interact effectively with physicians and medical coders to enhance diagnostic accuracy.

Documentation Expertise: Skilled in placing queries, clarifying diagnoses with physicians, and applying independent judgment while reviewing patient care documentation.

Compliance and Confidentiality: Ensures adherence to HIPAA regulations and maintains confidentiality of sensitive patient information.

Experience in working within EPIC and 3M 360 Encompass CAC

EMR Proficiency: Credentialed EPIC and Cerner EMR Consultant with over 10 years of experience in utilizing electronic health record systems.

Communication Skills: Strong written and verbal communication skills, with the ability to educate internal stakeholders and collaborate effectively with interdisciplinary teams.

Analytical Skills: Proficient in data analysis and report preparation, with a focus on achieving departmental goals and objectives.

EMPLOYMENT HISTORY

Clinical Documentation Specialist (Outpatient)

Arrowhead Regional Medical Center, Colton CA

03/2022 - Present

Facilitated comprehensive documentation supporting patient's illness severity and mortality risk

Kept abreast with ICD-10 CM & PCS coding, DRG systems, and AHA Coding Clinic & Coding guidelines

Ensured accurate clinical information for outcome measurement and reporting

Streamlined inpatient admission processes using MCG guidelines, enhancing workflow efficiency.

Boosted documentation accuracy, ensuring reliable measurement of hospital outcomes.

Provided ongoing education to physicians, elevating the standard of clinical documentation.

Monitored adherence to ICD-10 CM & PCS, improving coding accuracy and compliance.

Pioneered advanced query placement techniques, significantly clarifying diagnostic data.

Analyzed patient data to enhance clinical documentation, improving patient care quality.

Physician EMR Consultant/Physician Trainer

Various Hospitals across the United States and Canada

March/2012- March/2022

Provided one-on-one support to healthcare providers, reinforcing prior education and training on EPIC and Cerner usage.

Identified and resolved issues for client staff, serving as a point of escalation for complex issues.

Conducted training sessions and provided support in the use of EPIC and other clinical software applications.

Developed complex EPIC reports and liaised with stakeholders to coordinate report requirements and development activities.

Acted as a liaison for ICD-10 reporting and conducted clinical software training classes for physicians.

Developed and implemented training programs and materials to support end users of EPIC applications and clinical information systems.

EDUCATION

- Master of Science Healthcare Informatics

(Expected Graduation: 09/2024)

University of South Florida, Tampa, FL

- Certificate Course Health Informatics for Innovation, Value

07/2017

Columbia University in The City of New York, New York, NY

- M.D. Medicine and Surgery

11/2001

University of Ibadan, Ibadan, Nigeria

AFFILIATIONS

- Member, Association of Clinical Documentation Integrity Specialist

- Member, American Health Information Management Association

- Member, American Medical Informatics Association

- Member, Association of Clinical Research Professionals

- Member, Association of Foreign Medical Graduates

- Member, Botswana Health Professions Council

- Member, Nigerian Medical and Dental Council

- Member, American Association of Professional Coders

- Member, American Association of Medical Review Officers

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