Clinical Documentation Medical Records

PATRICIA A. LONG, RHIT, CCS

CODER/CDI SPECIALIST

*** ********* *****, ******, ** 30265 HOME 770-***-****) PRIMARY/CELL 404-***-****) ********@***.***

Summary

My professional history includes 7 years’ experience as a Clinical Documentation Specialist and over 30 years’ experience in Health Information Management Coding with advance knowledge in Inpatient DRG assignment.

My work ethics are dependable, conscientious, diligence, collaborator and self-disciplined in a remote working environment.

Experience

VIBRA HEALTHCARE OF SACRAMENTO, CA

Coder/Clinical Documentation Specialist 2018 – Present

Perform clinical documentation review daily on inpatients records and send providers query letters using Iodine CDI software template in reference to clarify diagnoses and procedures to meet patient care and documentation compliance.

Daily duties are abstracting, coding and sequencing ICD10CM/PCS codes on long term acute critical intensive care patient medical records using 3M encoder/DRG grouper.

Concurrently code inpatient in-house records and review clinical documentation for completeness and compliance, help case managers with inpatient and outpatient coding for surgical precertification.

Code outpatient records using CPT 4 code classification assignment.

TRUST HEALTH CARE CONSULTING, INC., SPRINGFIELD, MO

Coding Specialist 2013 – 2018

Performed inpatient coding & abstracting of medical records using 3M, Tru-code encoder, Epic and Meditech electronic medical record systems for multiple acute care hospitals ranging from 200 to 600 beds including the following specialties: multi-trauma, neurosurgery, orthopedic, OBYGYN, pediatrics and general surgery.

PERFORMANT RECOVERY, INC. SAN ANGELO, TX

Medical Review Specialist III (Recovery Audit Contractor 2012 – 2013

Performed coding reviews (DRG validation) for hospitals in the northeast region.

Researched and routed internal/external communications to the right person, department about requests for missing information reports.

Audited outpatient records for medical necessity on the following services: physical therapy, occupational therapy and speck therapy records.

PIEDMONT HOSPITAL, ATLANTA, GA

Clinical Documentation Specialist 2010 -2012

Reviewed medical records con-currently for quality, completeness and compliance. Coded potential DRGs Well Springs CDI tool with the use of 3M Encoder.

Occasionally conducted an in-service to the medical staff about clinical documentation.

Attended weekly meetings with the inpatient coding staff discussing physician documentation and coding issues including a discussion about the coding clinic topic for the week.

Education

IODINE CDI MONTHLY WEBINAR CERTIFICATES 2023 – 2024

Wellspring CDI Program Certificate of Completion July 22, 2010

ICD10CM/PCS Proficient

Certified Coding Specialist September 1997

Registered Health Information Technical October 1990

Chattahoochee Valley State Community College, Phenix City, AL

Associated in Applied Science Degree August 1984

University of Alabama, Birmingham, AL

AAS Degree and Medical Records Technical Certificate

Professional Organization

American Health Information Management Association Member

Georgia Medical Record Association Member

Awards: Compliance Officer’s Award

February 29, 2008

Leadership

Prior to accepting the CDS (Clinical Documentation Specialist) position at Piedmont Atlanta, I served as Coding Manager at Piedmont Newnan from 2007 to 2010. I also was a Battalion Commander in ROTC my senior year of high school in 1981.

References

Available Upon Request

Contact this candidate