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MD, CDIP, Clinical Documentation Improvement Specialist

Snellville, GA
March 23, 2023

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**** ****** *** *. ********** GA. 30039

Phone: 404-***-**** LinkedIn:

Email address:

OBJECTIVE: Seeking a position as a Clinical Documentation Integrity Specialist


All Saints University College of Medicine, Saint Vincent, and the Grenadines

Doctor of Medicine 2014-2019

Madonna University, Elele, Rivers State, Nigeria

Basic Medical Science 2010-2013

CDIP Certified 2023


Knowledge of clinical documentation guidelines

Experience in medical terminologies, clinical documentation and ICD 10 coding.

Knowledgeable in utilization of electronic medical record systems (Cerner, EPIC,)

Great background in patient chart reviewing and patient note taking

Good written and verbal communication skills

Adequate critical thinking skills and ability to assess, evaluate, and teach

Knowledge of PC, MS Word, Excel, Internet, Email, Power Point Software

Extensive knowledge of complex disease processes and treatment methodology

Knowledge of ICD-10-CM, CPT coding, DRG, and HCCs

Conversant with 3M 360, EPIC, Meditech, NextGen, Athena, eClinical Works, Practice fusion, Kareo

Broad-based clinical experience in an outpatient and inpatient setting

Highly familiar with Medicare parts A and B


Internal Medicine, Obstetrics and Gynecology, Pediatrics, Family Medicine, Psychiatry, Surgery, Pain Management, Neurology, Pulmonology, Infectious Disease and Cardiology (Internship or Clinical rotation done in Atlanta Medical Center, DeKalb Medical Center, Wellstar Hospital and some Doctors offices in Atlanta, Georgia).

Assisted physicians with clinical documentation to meet Medicare guidelines.

Clinical educational presentations on a monthly basis.

Experience in medical terminologies, clinical documentation and ICD 10 coding.

Patient chart reviewing and patient clinical documentation of history and physical

Became skilled at clinical procedures such as vital signs, Electrocardiogram (EKG), Allergy testing, Phlebotomy, wound care, and sutures.

Analyzed patient findings and collaborated with various medical personnel to formulate and execute treatment plans.

Reviewed, analyzed, and presented current medical literature during conference rounds.


FOS Consulting LLC Feb 2022 - Current

Clinical Documentation Integrity Consultant

Reviewing patient medical records in the inpatient and/or outpatient setting to capture accurate representation of the severity of illness and facilitate proper coding.

Validates coding reflects medical necessity of services and facilitates appropriate coding which provides an accurate reflection and reporting of the severity of the patient's illness along with expected risk of mortality and complexity of care.

Documentation of discharge diagnoses and co-morbidities are a complete reflection of the patient's clinical status and care.

Utilizes advanced knowledge of disease processes (pathophysiology), medications, and have critical thinking skills to analyze current documentation to identify gaps.

Identifies opportunities in concurrent and retrospective inpatient clinical medical documentation to support quality and effective coding.

Understands and applies regulatory compliance related to documentation, coding and billing for all health insurance plans.

Facilitates appropriate modifications to documentation through extensive interactions and collaboration with physicians, coding, case management, nursing and other care givers.

Serves as an effective change agent as an educator and resource for physicians and allied health staff to improve the quality and completeness of the clinical documentation.

Prime Healthcare, Ontario, CA Dec 2019 – Dec 2022

Inpatient/Outpatient CDI Specialist

Conduct daily concurrent and retrospective medical chart reviews to ensure accurate documentation supporting diagnoses and procedure codes - ICD-10-CM, CPT, Evaluation and Management (E/M) Levels.

Formulate clinically focused clarifications queries to providers to obtain accurate and complete documentation as needed.

Strategically educate patient-care team members regarding documentation regulations and coding guidelines, including attending physicians, allied health practitioners, and Physician Assistants. This includes recognizing opportunities for documentation improvement, quarterly updates, and progress reports to individual providers.

Create and develop educational PowerPoint presentations and Tip sheets for medical providers.

Report findings of chart review and clinical documentation improvement opportunities to providers to maximize the coding of ongoing risk-adjusted conditions.

Collect analyze, and report data pertinent to documentation issues and make recommendations for improvement.

Communicates with physicians, nursing staff, OT, ST, RT, RD, case managers, and other healthcare team members to achieve complete and accurate clinical documentation.

Review the daily updates to reflect any new diagnoses, procedures performed, and treatment changes.

Rosary Makers of America, Stone Mountain, GA Jan 2021 – Feb 2022


Grant writing and application


Oversee day to day activities of our participants with special needs

Hiring personnel, maintaining personnel records, and ensuring insurance policies are up to date

Develop and manage budgets for all administrative departments

Review operating costs and suggest alternative, cost-saving measures

Oversee and evaluate IT network systems

Negotiate vendor pricing, contracts, and terms

Act as primary liaison with the building landlord

Oversee office operating procedures

Primary Diagnostic Systems, Atlanta, GA Oct 2018 – Nov 2020

Patient Care Coordinator/Medical Operations

Promoting and implementing vital screening tests in various clinical practices to improve patient care.

Increasing monthly revenue by completing monthly Medicare-approved programs.

Researching the financial saving of BPP (Bennett polypharmacy profile) on the Medicare and Medicaid system.

Managing various clinic accounts and supervising lab technicians while analyzing lab results.

Conducting research and taking classes to assist in conducting treatment for drug abuse.

Leading training sessions to teach lab technicians how to perform screening tests and procedures properly.

Managing working relationships with various labs, clinics, and Doctor offices.

Provided quality assurance on lab samples and mastered a deep understanding of different lab systems.

Using data to do analytical tasks and charting tasks related to patient information

Communicating with patients about their status and condition through emails, phone, and face-face conversations.

Managing patient accounts with contact information, insurance, and financial information in a confidential manner

Scheduling patient visits and answering questions, including billing and preparation

Ensuring services comply with state and federal regulatory requirements.

Spear headed COVID-19 vaccine and testing

JJP Internal Medicine, Atlanta, GA March 2018 – October 2018

Medical Assistant

Assisted physicians to examine and treat patients, handing them instruments, and giving injections or removing sutures.

Prepared patients for exams, took medical histories and vital signs, and assisted during exams for over 20 patients a day.

Acquired patient vitals and recorded information into medical files for proper maintenance, accuracy, and follow-up.

Performed preliminary physical tests, taking blood pressure, weight, and temperature.

Maintained medical supplies inventory and performed preventive maintenance to keep medical equipment operating.

Verified patient information by interviewing patients, recording medical history, and confirming the purpose of the visit.

Scheduled surgeries by planning with the surgical center, verifying times with patients, and preparing charts and pre-admission and consent forms.


CERTIFICATIONS: Basic Cardiac Life Support Provider, Advance Cardiac Life Support Provider, Health Insurance Portability and Accountability Act. AHIMA CDIP. ECFMG

SKILLS: Microsoft Word, Excel, PowerPoint, Outlook, Access and Electronic Medical Records (EMR)- Cerner, Epic, eClinical Works, Meditech etc.3M 360


Dean’s List April 2016


John Emmanuel MD CCDS CCS

Associate CDI Director

Emory University Hospital

Emory Orthopedic and Spine Hospital Atlanta GA

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