Medical Records Inpatient Coding

Rosemary Brent

**** ******* *****, **** *

Killeen Texas, 76549

Phone: 254-***-****

Email: *******@***.***

EXPERIENCE:

Supervisory, Medical Records Technician

Darnall Army Medical Center - Fort Cavazos, TX January 2016 to June 2020

(Retired - June 2020)

Trained inpatient/outpatient medical coders

Trained physicians/peers regarding specificities of documentation improvement/medical record

Approved leave for employees

Performance Appraisals

Educated clinical staff on proper charting/documentation practices, inpatient coding guidelines/regulations according to industry standards

Mentored new hires on proper handling/documentation/storage techniques for sensitive patient information and inpatient coding guidelines

Increased productivity by implementing workflow improvements within the Medical Records Department and weekly training session for inpatient coding with continue education certificates given to employees

Spearheaded initiatives to digitize historical paper-based records for long-term storage purposes (retirement of records)

Liaised with external/internal auditors during regulatory inspections or audits related to inpatient coding

Collaborated with IT department on system upgrades or enhancements related to electronic health records

Investigated complaints or concerns regarding medical record management, inpatient coding and taking appropriate corrective actions when necessary

Clinical Documentation Improvement Specialist

Veterans Administration Medical Center - Temple, TXJanuary 2014 to December 2015

Analyzed medical records for Diagnostic Related Group’s complications and comorbidities

Improved overall quality of completeness of clinical documentation

Extensive interaction with physicians, nursing staff, other patient care givers and medical records staff for appropriate reimbursement

Collaborated with healthcare providers to clarify and obtain missing or incomplete documentation

Maintained up-to-date knowledge of coding guidelines, regulations, and compliance requirements

Performed regular audits of clinical documentation for quality assurance purposes

Identified opportunities for improvement in clinical documentation processes and implemented solutions

Ensured that all patient records met the standards required for billing and reimbursement purposes

Provided education to healthcare staff on proper clinical documentation practices and compliance standards

Participated in interdisciplinary team meetings to discuss patient care plans based on documented information

Supported coding professionals by providing accurate clinical details for code assignment purposes

Developed standardized templates for documenting common procedures leading to improved consistency across records

Served as a subject matter expert during internal audits ensuring compliance with regulatory standards at all times

Medical Records Technician

Veterans Administration Medical Center - Tuskegee, ALJanuary 2007 to December 2009

Abstracted and coded inpatient medical records

Abstracted and coded fee basis records

Accurately assigned ICD-10-CM and PCS codes to inpatient medical records, ensuring compliance with coding guidelines and regulations

Reviewed patient charts, laboratory results, and physician documentation to extract relevant information for coding purposes

Collaborated with healthcare providers to clarify diagnoses and procedures when necessary, ensuring accurate code assignment

Maintained a high level of productivity while meeting quality standards for coding accuracy and completeness

Utilized electronic health record (EHR) systems and coding software to assign appropriate codes based on medical documentation

Performed regular audits of coded records to identify any discrepancies or errors, making necessary corrections as needed

Stayed up-to-date with changes in coding guidelines, regulations, and industry best practices through continuous education and training programs

Worked closely with billing department to resolve any coding-related issues or denials that may arise during claims processing

Collaborated with interdisciplinary teams including physicians, nurses, case managers, and other healthcare professionals to ensure accurate code assignment

Education

Associate of Science degree in Information Management

Temple Junior College - Temple, TXMay 1986

Temple High School - Temple, TX1979

Skills

Transcription

Clinical documentation improvement

Medical records

Documentation review

ICD-10

Mentoring

Supervising experience

Microsoft Word, Excel, Graphics (programs and flyers) Social Media: Facebook and Zoom

Time management

Revenue cycle management

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