CLINICAL DOCUMENTATION SPECIALIST (CDS) - ST. JOSEPH HOSPITAL
(2025-06)
- Perform concurrent inpatient clinical documentation reviews to ensure accuracy, completeness, and compliance for MS-DRG assignment, SOI/ROM capture, and medical necessity.
- Analyze clinical indicators, progress notes, medications, imaging, and labs to validate documentation and identify opportunities for improved specificity.
- Develop and issue compliant provider clarification queries using standardized formats to support accurate diagnosis and procedure reporting.
- Collaborate closely with Coding, Case Management, and Providers to resolve documentation discrepancies and support real-time documentation improvement.
- Utilize Nuance CDI software for case prioritization, workflow management, query tracking, and documentation review efficiency.
- Conduct targeted PSI (Patient Safety Indicator) reviews to confirm documentation accuracy, evaluate exclusions, and ensure correct attribution without misclassifying events.
- Review POA status, evaluate clinical timing, and communicate with Quality/Coding teams as needed to clarify potential complications or PSI triggers.
- Support organizational financial performance and compliance through accurate documentation, improved DRG integrity, and reduced audit/denial risk.
- Provide ongoing provider education related to documentation best practices, specificity requirements, and clinical indicator alignment.
CLINICAL DOCUMENTATION SPECIALIST - ELMHURST HOSPITAL - QUEENS, NY
(2018 - 2025-05)
Operate within a multifaceted and all-encompassing leadership role, overseeing daily responsibilities, including facilitating appropriate provider's documentation via concurrent, prospective, and retrospective medical record reviews. Implement quality improvement initiatives to enhance precision and efficacy of clinical documentation practices.
- Utilize advanced knowledge of medical terminologies and procedures for interpreting test results and identifying individual illness severity as well as ensuring clinical data validity to optimize patient care services.
- Work collaboratively with a multidisciplinary team of highly-competitive healthcare professionals, including health information managers, and medical coders to resolve coding and compliance concerns.
- Exhibit denials management expertise by crafting customized denial appeal letters while navigating Medicare, Medicaid, and third-party payer guidelines.
- Perform a pivotal role in special projects for the denials team, actively identifying denial patterns and recommending strategic improvements to work queues and claim edits, contributing to process improvement initiatives, enhancing operational efficiency, reducing denials.
- Regularly review inpatient healthcare records to facilitate discharge summaries and reimbursement procedures identifying opportunities for process improvements.
- Serve as a consultant for coding professionals while performing medical record reviews, conducting quality, and assigning accurate codes to complex data.
- Steer and direct ongoing education sessions for healthcare providers, including coding staff, physicians, and nurses to elevate awareness on standard procedures and improve overall record keeping processes.
- Ensure concise documentation and resolution of valued clientele queries regarding complex health problems, along with recording physician responses to optimize reimbursement.
- Thrive within fast-paced hospital work environment while handling high-volume update in coding guidelines.
TEACHER AIDE - KIDS FIRST - WESTBURY, NY
(2017 - 2018)
- Acted as a Teacher Aide in Hempstead ABGS school and Hempstead Jackson Annex elementary school, working collaboratively with the course teacher to assist students with instructional and non-instructional initiatives.
- Executed an integral role, creating engaging lesson plans, stimulating positive environment, and promoting behavior modification while delivering customized 1-on-1 and group learning sessions.
- Utilized inquiry-based and experiential learning strategies to enhance student performance and capabilities.
- Created a student-centered environment to promote student interests in classroom activities and assignments.
OFFICE COORDINATOR - EXPRESS MEDICAL CENTER - LYNBROOK, NY
(2015 - 2016)
- Performed administrative duties, including assisting patients with paperwork, scheduling appointments, and maintaining electronic records while restructuring workflow to streamline facility operations with excellence.
- Operated as a main point of contact for responding to patient inquiries, resolving visitor complaints, and addressing client concerns on patient invoicing, insurance claim submissions, and reimbursement procedures.
- Implemented health record management best practices to organize and update patient account details, treatment processes, and financial information while ensuring compliance with data confidentiality regulations.
HEAD OF AUTHORIZATION DEPT., HEALTH INSURANCE - EURO-ARAB INSURANCE CO - AMMAN, JORDAN
(2013 - 2015)
- Provided high-quality authorization services via integrating advanced technology solutions, thus maximizing information accessibility, minimizing errors, improving data accuracy, and reducing processing times.
- Conceptualized robust crises intervention strategies to meet contingencies, navigate escalated authorization issues, and solve discrepancies while maintaining mutually beneficial relationships with key stakeholders.
- Conducted financial planning and analyses, determining authorization requirements based on plan type, service place, and patient benefits, thus generating cost optimization and ensuring optimum resource allocation.
REGISTERED NURSE, ICU - ARAB MEDICAL CENTER - AMMAN, JORDAN
(2008 - 2014)
- Evaluated and assessed pre-mature babies care needs via performing routine check-ups, monitoring clinical status, recording nursing assessments, and generating reports to ensure patient optimal health and well-being.
- Administered prescribed medication and treatment plans for new borns in NICU, including injections, fluids, and blood transfusions while maintaining facility equipment to optimize new born babies' protection and safety.
