Healthcare Documentation Specialist
AQuity Solutions India Pvt. Ltd.
Total des années d'expérience :14 years, 4 Mois
• Improved documentation process efficiency by standardizing templates and protocols to follow.
• Assigned appropriate codes to each diagnosis, encounter.
• Knowledge of 3M coding software, which improved productivity.
• Reduced document hold time by adhering to First Time Right methodology.
• Documented and assigned codes on 15 to 20 medical reports like History and Physical, Consultation, Operation Report, and Discharge/Transfer Summaries. Radiology reports like CT/CTA, MRI/MRA, x-rays, ultrasound, and diagnostic testing.
• Controlled Quality especially Critical Errors by adhering patient-safety policy.
• Read and analysed patient health records to evaluate any demographic errors, encounter errors, data integrity, and/or ADT. If any discrepancies found, alert physicians or physician assistant for more information.
• Determined correct codes for each diagnosis and procedures.
• Collaborated with physicians, nursing assistant, CRMs for any issues with quality.
• Extensive knowledge on disease process, anatomy, physiology, medical terminology to appropriately document diagnosis and procedures performed.
• Knowledge of EPIC, Cerner and how they help to monitor disease trends and quality of care.
Improved documentation process efficiency by standardizing protocols to follow.
Reduced application time by minimizing hold time and adhering to First Time Right methodology.
Capacity planning and serving global clients 24/7.
Collaborated between patient, physicians, and payers.
Compliant with ISO9001, HIPAA, PHI, medical necessity.
Conducted internet research on advancement in healthcare documentation and trained associates to be open for new challenges and requirements for EMR, PACS, HIMS, Interoperability.
Evaluated patient health records, ensured documents are error-free, and standard of
services are delivered.
Controlled Quality of various patient health records like History and Physical, Consultations, Operative Reports, Discharge/Transfer Summaries, CT/MRI, Echo, TEE, EGD, and other Ambulatory Surgery Center reports.
Converted dictated medical records by physicians into documents, process them per physician request and style with attention to patient confidentiality using Dictaphone, eScription, Fluency.
Knowledge in disease processes, pharmacology, anatomy and physiology, HIPAA, privacy
and confidentiality, and diverse technologies used to capture health data.
*Provided services to various hospitals in the US assisting them in clinical documentation and clinical management remotely using Dictaphone and eScription.
*Trained freshers from various institutions and getting them into organization.
*Served under pressure to achieve goals and task provided by management.
*Transcribe medical reports recorded by physicians and other healthcare practitioners using various electronic devices, covering office visits, emergency room visits, diagnostic imaging studies, operations, chart reviews, and final summaries.
*Good experience in assisting and evaluating the operational procedures, the metrics and identify all the existing inefficiencies and provide feedback to team members.
*Document dictated reports and translate abbreviations into fully understandable form. Edit as necessary and return reports in either printed or electronic form for review and signature, or correction.
Project Management, Operations Management, Organization Behavior, Business Principles, Customer Relationship, Database, Healthcare
One of the esteemed college in Vaniyambadi, Islamiah College. This is an six decade old institution and has catered a huge number of student into various walks of life from arts to science to technology and so on. This is an highly prestigious institution of our district. Learned Database, Networking, MS Office, Internet, Data structure, RDBMS, Computer Graphics