Neethu M Jose
Clinical Documentation Specialist (DRG Process) | Clinical Documentation Improvement (CDI) | Registered Nurse | Nurse Educator
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About
NCLEX-RN Certified Registered Nurse with over 12 years of progressive experience spanning clinical nursing, clinical documentation improvement (CDI), nursing education, and primary healthcare services. Experienced in reviewing medical records for documentation accuracy, DRG validation, ICD-10 compliant documentation, and physician query support while ensuring coding integrity and regulatory compliance. Demonstrated expertise in medical-surgical nursing, psychiatric nursing, community health, patient assessment, multidisciplinary collaboration, and quality improvement initiatives.
Recognized for delivering high-quality patient care, improving clinical documentation standards, and mentoring future nursing professionals. Seeking opportunities in Clinical Documentation Improvement (CDI), DRG Validation, Utilization Management, Quality, Healthcare Documentation, Nursing Leadership, or Clinical Audit.
Experience
Clinical Documentation Specialist (DRG Process) - CorroHealth
(2024-04)
- Review inpatient medical records to ensure complete, accurate, and compliant clinical documentation.
- Perform DRG validation by evaluating diagnoses, procedures, and supporting clinical evidence.
- Identify documentation gaps and recommend appropriate physician clarifications.
- Support accurate ICD-10 coding through comprehensive documentation review.
- Ensure documentation aligns with regulatory standards, payer requirements, and coding guidelines.
- Collaborate with coding teams to improve documentation quality and reimbursement accuracy.
- Analyze medical records to identify opportunities for Clinical Documentation Improvement (CDI).
- Maintain documentation quality while meeting productivity and accuracy benchmarks.
- Participate in internal quality audits and documentation improvement initiatives.
- Promote documentation best practices to improve coding integrity and clinical outcomes.
MLSP Staff Nurse - Primary Health Centre Ayyappancoil - Ayyappancoil, Idukki, Kerala
(2021-02 - 2023-12)
- Delivered comprehensive primary healthcare services across outpatient and community settings.
- Performed patient assessments, diagnosis support, treatment planning, and follow-up care.
- Managed preventive healthcare, maternal and child health, immunization, and chronic disease management.
- Conducted health education and awareness programs within the community.
- Maintained complete clinical documentation and patient health records.
- Coordinated referrals and collaborated with multidisciplinary healthcare teams.
- Assisted in emergency stabilization and first-line patient management.
- Supported implementation of government healthcare initiatives and public health programs.
Clinical Assistant - Sagar Hospitals - Bengaluru
(2016-07 - 2020-02)
- Assisted consultants in managing inpatient and outpatient clinical services.
- Conducted comprehensive patient assessments and monitored clinical progress.
- Recorded vital signs, clinical observations, and treatment responses.
- Coordinated emergency care and patient admissions.
- Maintained accurate clinical documentation and medical records.
- Ensured adherence to hospital policies, infection control, and patient safety protocols.
- Collaborated with multidisciplinary teams to optimize patient care.
- Educated patients and families regarding treatment plans and discharge instructions.
Assistant Professor – Psychiatric Nursing - Christian College of Nursing - Bengaluru
(2013-06 - 2016-01)
- Delivered undergraduate nursing education in psychiatric and mental health nursing.
- Developed lesson plans, academic content, and clinical training modules.
- Supervised students during hospital clinical postings.
- Conducted student evaluations and competency assessments.
- Mentored students in research activities and evidence-based nursing practice.
- Participated in curriculum planning, accreditation activities, and academic quality initiatives.
Lecturer – Psychiatric Nursing - Mar Sleeva College of Nursing - Kerala
(2012-07 - 2013-04)
- Conducted classroom teaching and clinical instruction in psychiatric nursing.
- Facilitated practical demonstrations and simulation-based learning.
- Guided students during clinical rotations.
- Prepared educational materials, examinations, and academic assessments.
- Promoted professional development and ethical nursing practices.
Staff Nurse – Medical & Surgical Department - St. John's Hospital - Kerala
(2009-04 - 2010-07)
- Delivered direct nursing care for medical and surgical patients.
- Administered medications and monitored treatment outcomes.
- Assisted physicians during clinical procedures and emergency interventions.
- Performed wound care, patient assessments, and post-operative monitoring.
- Maintained comprehensive nursing documentation and patient records.
- Ensured compliance with infection prevention and patient safety standards.
Education
Master of Science (M.Sc.) - Psychiatric Nursing - Rajiv Gandhi University of Health Sciences
Bachelor of Science (B.Sc.) - Nursing - Rajiv Gandhi University of Health Sciences
