Clinical Documentation Improvement Specialist

CYRIL VENTA, RN, BSN

Clinical Care Coordinator

Romeoville, IL 60446 ***********@*****.*** 630-***-**** PROFESSIONAL SUMMARY

RN, BSN with 15+ years of clinical experience with 11 years in skilled nursing, long-term care, and acute care settings. Demonstrated expertise in concurrent clinical documentation review, utilization review, ICD-10-CM diagnostic coding, and physician query processes to support severity of illness, and accurate DRG assignment. Proven ability to identify comorbidities, complications, and secondary diagnoses that drive quality ratings and reimbursement optimization. Skilled collaborator with physicians and clinical staff; experienced in clinical staff education, documentation compliance, and legal health record integrity. Passionate about transitioning into a hospital-based CDI role to leverage clinical knowledge and coding expertise in an inpatient environment. CORE COMPETENCIES

• Concurrent Clinical Documentation Review • Severity of Illness (SOI) / Risk of Mortality

(ROM)

• Physician Query & Medical Staff Education •Primary diagnosis identification and PDPM mapping/optimization and Secondary Diagnosis

Identification

• ICD-10-CM Diagnostic & Procedure Coding • IDT collaboration

• Medicare/Medicaid Reimbursement Compliance • Clinical Quality Rating & Proofing

• Chart Review • Legal Health Record Privacy & Confidentiality

(HIPAA)

• Documentation Discrepancy Resolution • PointClickCare, Vision EMR, Microsoft Office Suite

PROFESSIONAL EXPERIENCE

Clinical Care Coordinator

Lexington Health Network / Bella Terra Lombard Lombard, IL July 2015 – April 2026

• Perform thorough concurrent review of clinical documentation in medical records to identify and capture comorbidities, complications (CC/MCC), and secondary diagnoses that impact severity of illness, risk of mortality, and quality ratings.

• Query physicians and clinical staff to obtain accurate, complete documentation that appropriately reflects the patient's clinical condition and supports compliant Medicare/Medicaid reimbursement and PDPM optimization.

• Assign ICD-10-CM diagnostic and procedure codes for all admissions and conduct post-discharge coding review to ensure accurate classification and receipt of legitimate reimbursement.

• Document identified comorbidities and complications within concurrent PDPM worksheets; track secondary diagnoses to support quality rating and proofing processes.

• Educate medical staff on documentation best practices, coding requirements, and the importance of capturing all appropriate secondary diagnoses; deliver ongoing feedback to improve documentation integrity.

• Collaborate with physicians, case managers, and IDT members to resolve documentation discrepancies and support Medicare/Medicaid and Managed Care reimbursement compliance.

• Maintain the highest standard of privacy and confidentiality in the legal health record in accordance with HIPAA Standards of Conduct.

• Prepare facility for surveys, audits, and reimbursement reviews through rigorous documentation standards and corrective action plans.

MDS Director

Winchester House Libertyville, IL November 2017 – March 2018 (while working prn at Lexington)

• Assigned ICD-10-CM diagnostic codes and completed concurrent clinical documentation review for all skilled and long-term residents, ensuring accuracy and completeness.

• Directed full MDS office operations; performed thorough chart reviews to identify comorbidities and ensure documentation supported accurate classification and reimbursement.

• Conducted triple-check process with therapy and billing teams to ensure reimbursement accuracy and regulatory compliance.

MDS Coordinator

Bridgeway Rehabilitation Services Bensenville, IL March 2018 – July 2018

• Completed concurrent MDS assessments; reviewed clinical records for documentation accuracy, coverage, and utilization to support compliant reimbursement and post-discharge coding.

• Identified documentation gaps and discrepancies; collaborated with clinical staff to resolve issues and ensure legal health record integrity.

Clinical Reimbursement Coordinator (PRN)

Lexington Healthcare Elmhurst and Lombard, IL July 2015 – April 2026

• Completed MDS assessments and served as backup MDS Director, managing all concurrent documentation review and ICD-10 coding responsibilities independently.

• Reviewed clinical records for coverage, utilization, and accurate documentation; submitted and corrected assessments per CMS standards.

Registered Nurse (RN)

Wynscape Nursing Home and Rehab Winfield, IL April 2013 – July 2015

• Delivered hands on clinical care in a sub-acute rehab setting; completed new admission assessments and clinical documentation for a post-surgical geriatric population. Registered Nurse (RN)

Snow Valley Rehab- Lisle, IL

February 2011- March 2013

• Delivered hands on clinical care in a long-term facility; completed wound treatments, administered medications, IV infusions, g-tube feedings, colostomy changes for a geriatric population. Registered Nurse (RN)

St. Alexius Medical Center Hoffman Estates, IL November 2009 – January 2011

• Provided care on a medical-surgical unit; performed new admission assessments and comprehensive patient documentation including medication reconciliation, IV therapy, TPN, blood transfusions, and insulin/heparin drips.

• Served as charge nurse; coordinated care for a diverse medical-surgical population across multiple clinical diagnoses.

Registered Nurse (RN)

Swedish American Hospital Rockford, IL October 2008 – November 2009

• Provided direct patient care on a medical-surgical unit; completed patient assessments, documentation, and care coordination in a fast-paced high acuity care environment. EDUCATION

Bachelor of Science in Nursing (BSN)

Chamberlain College of Nursing 2013 – 2014

Associate of Applied Science – Nursing

College of DuPage, Glen Ellyn, IL 2004 – 2008

LICENSES & CERTIFICATIONS

• Active Illinois Registered Nurse (RN) License

• CMAC Certified – MDS/RAI Certification- to be renewed

• BLS & CPR Certified

• ACLS Certified

TECHNICAL SKILLS

EHR/Software: PointClickCare, CareWatch, Vision EMR (5 yrs), Net Health Therapy, Casamba, Microsoft Office Suite (15+ yrs)

Clinical: ICD-10-CM Diagnostic & Procedure Coding, Concurrent Documentation Review, PDPM mapping,, Physician Query Process, Triple Check billing process, UB claim review, MDS/RAI (15+ yrs), PDPM & RUGS, Utilization Review, Comorbidity Identification, Legal Health Record Compliance, Medication Reconciliation, Careplan Management

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