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Documentation Improvement Specialist Resume Examples & Templates

Nilda Melissa Diaz, CPRW
By Nilda Melissa Diaz, CPRW, Career Advice Expert Last Updated: November 10, 2023

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Clinical documentation improvement specialists organize medical information from patients and physicians. Your expertise in documentation, medical coding, data quality and data collection help physicians and medical institutions improve their services. 

Advance your career with a well-written clinical documentation improvement specialist resume. Our guide can help you create an effective clinical documentation improvement specialist resume to showcase your skills and present you as a desirable candidate.

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Clinical documentation improvement specialist resume example (text version)

Nathan O’Connor

Philadelphia, PA 19111
(555) 555-5555
example@example.com

Professional Summary

Detail-oriented clinical documentation improvement (CDI) specialist with eight years of experience optimizing health care documentation practices to enhance patient care, compliance and revenue integrity. Proficient in conducting comprehensive chart reviews, offering actionable feedback to health care providers and implementing effective documentation improvement strategies. Adept at identifying areas for process enhancement and ensuring compliance with coding and billing regulations.

Work History
November 2021 – Current
Jefferson Center – Philadelphia, PA
Clinical Documentation Improvement Specialist

  • Achieve a 20% reduction in documentation discrepancies and coding inaccuracies through comprehensive chart reviews, identifying documentation deficiencies, coding inaccuracies and compliance issues.
  • Collaborate with health care providers to offer education and feedback on documentation improvement.
  • Work with interdisciplinary teams to implement CDI initiatives, resulting in a 25% reduction in compliance-related penalties.

September 2018 – October 2021
Abington Hospital – Philadelphia, PA
Health Information Specialist

  • Managed electronic health records (EHR) and ensured the completeness and accuracy of patient data.
  • Collaborated with physicians, nurses and coding staff to clarify documentation discrepancies for over 500 patient records.
  • Assisted in transitioning from paper records to EHR systems, ensuring data integrity and compliance, resulting in a 25% reduction in administrative workload.

June 2015 – August 2018
Valley Health System – Philadelphia, PA
Health Information Technician

  • Successfully conducted annual HIPAA audits, resulting in a 100% compliance rating.
  • Conducted routine quality assurance audits in patient records and achieved a 98% accuracy rate in documentation, minimizing risks of denied claims and legal issues.
  • Assigned appropriate medical codes (e.g., ICD-10, CPT) to diagnoses and procedures for billing and reimbursement purposes, resulting in a 15% increase in clean claim submissions and faster reimbursement turnaround.

Skills

  • Clinical documentation review
  • ICD-10-CM coding
  • CPT coding
  • Medical terminology
  • Electronic Health Records (EHR)
  • Compliance and auditing
  • Interdisciplinary communication
  • Data analysis
  • Time management
  • Problem-solving

Education

June 2015
Temple University Philadelphia, PA
Bachelor of Science Health Information Management

Certifications

Certified Clinical Documentation Specialist (CCDS) – (2023)

5 essentials of a top clinical documentation improvement specialist resume

  1. Contact details

    Start with the basics: the clinical documentation improvement specialist resume contact details section. The standard goes: full name, city, state and ZIP code, followed by phone number and email address. Finally, add a professional website or any other professional networking profile, like LinkedIn or a membership organization.

  2. Personal statement

    The professional summary of your clinical documentation improvement specialist resume is your introduction to the hiring manager. In no more than five sentences, present your best skills and your related work experience. Include how long you have been in the industry, one or two professional accomplishments and your job-relevant skills. Always tailor this section to the particular job description, as this is the first section a hiring manager will read.

  3. Skills

    Build the clinical documentation improvement specialist resume skills section using a bulleted list for an easy read. Remember, the skills will show what you bring to the table and how you work with others. Include keywords from the job description to capture the hiring manager’s attention. Use hard skills, like medical coding and eClinicalWorks EHR software, and soft skills, such as relationship building and research.

    If this is your first job as a clinical documentation improvement specialist, you can include transferable skills from other employment.

  4. Work history

    In this section, you’ll highlight your clinical documentation improvement specialist duties. List your work history in reverse-chronological order and add the company names, locations and dates of employment.

    For every job, include a bulleted list of three measurable accomplishments, like the amount of reviews completed, effective collaboration with medical staff and training healthcare staff in documentation procedures. Use the clinical documentation improvement specialist job description for a resume to tailor this section. 

    If this is your first job, you can include other relevant work experience, like volunteer experiences, community services, professional projects and more.

  5. Education

    Create an education section for your clinical documentation improvement specialist resume and  include the educational institution’s name, the degree conferred and graduation year. Skip the year if it has been more than 10 years. If you did not attend college, list your high school and any other post-high school course you’ve completed.

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Do’s and don’ts for building an clinical documentation improvement specialist resume

  • Use measurable achievements to describe your clinical documentation improvement specialist skills and experience.
  • Use action words to make an impact on your clinical documentation improvement specialist resume.
  • Tailor your resume to your target clinical documentation improvement specialist job.
  • Use keywords from the job description throughout your clinical documentation improvement specialist resume.
  • Format your clinical documentation improvement specialist resume so that it is easy to read by ATS software and human eyes.
  • Lie about your clinical documentation improvement specialist experience and skills.
  • Boast about your “incomparable” clinical documentation improvement specialist abilities.
  • Include irrelevant personal information such as your ethnicity and age.
  • Add skills and experience that do not pertain to a clinical documentation improvement specialist.
  • Forget to proofread. A clinical documentation improvement specialist resume with errors is unprofessional and will be discarded.

Top 4 tips for acing a clinical documentation improvement specialist interview

  1. Research the company before your interview.

    Research the institution’s history, goals, and values through its official website, social media and the news. This knowledge will show your potential employer interest, dedication and commitment — traits that hiring managers look for in every candidate. It will also help you craft your own questions for the interviewer. 

  2. Practice at home.

    Prepare for any scenario by practicing an interview with the help of a friend or relative. Start by reviewing the most common interview questions, such as: 

    Research other possible interview questions, write down your answers and then practice with your interview partner. Ask them for feedback on your answers and body language, and work with them to improve. Being prepared will boost your confidence and chances of getting a callback for a second clinical documentation improvement specialist interview.  

    Pro tip: Practice in front of a mirror. Remember to look at both your facial expressions and body language, which hiring managers will notice.

  3. Be proactive and ask questions.

    You are also interviewing the employer. Prepare at least three that will help you learn more about the company, their mission and values and the role. Get started with these examples: 

    • Why did you choose to work here?
    • What steps do you take to ensure continued training and development?
    • What could you tell me about the culture and environment?

    Use open-ended questions and allow the interviewer to answer before moving on to the next one. You can bring a small notebook or piece of paper with your questions written down.

  4. Gather your references.

    Contact former managers and colleagues to be potential references as you start applying for clinical documentation improvement specialist positions. Your potential references should be able to vouch for your work ethic and skills. Explain to them where you are in the process and let them know they could receive a phone call or email. Also, request at least two letters of recommendation for you. 

    If this is your first full-time job as a clinical documentation improvement specialist, you can request a reference from a mentor or instructor, an individual that can vouch for your skills.

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