Having a strong resume is essential when applying for a Clinical Documentation Improvement Specialist role. A resume that stands out among the other applicants is a key factor in landing an interview. To ensure your resume is competitive, follow this guide and use the accompanying examples to create a resume that gets noticed by potential employers. This guide will cover all the aspects that are essential to creating an effective resume for a Clinical Documentation Improvement Specialist position, from formatting and content to industry-specific best practices.
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Clinical Documentation Improvement Specialist Resume Examples
John Doe
Clinical Documentation Improvement Specialist
123 Main Street | Anytown, USA 99999 | Phone: (123) 456-7890 | Email: john.doe@email.com
Highly experienced and motivated Clinical Documentation Improvement Specialist with 10+ years of experience in healthcare documentation, coding, and auditing. Effective communicator providing expertise in medical terminology, evaluation and management services, and ICD- 10 coding. Adept at using Cerner, eClinicalWorks, and Epic systems. Certified Clinical Documentation Improvement Practitioner who is organized, detail- oriented, and has a strong commitment to improving patient care.
Core Skills:
- Clinical documentation
- Coding and auditing
- Medical terminology
- Evaluation and management services
- ICD- 10 coding
- Cerner, eClinicalWorks, Epic systems
- Compliance
- Quality assurance
- Risk management
Professional Experience:
Clinical Documentation Improvement Specialist, ABC Healthcare Inc., 2014 – Present
- Implement and manage Clinical Documentation Improvement (CDI) program, including standards, procedure, and processes
- Monitor and audit medical records for accuracy and completeness
- Coordinate with clinicians to resolve discrepancies and ensure correct information is documented
- Educate and train staff on clinical documentation requirements
- Review and analyze clinical data to identify patterns and gaps in documentation
Coding and Auditing Specialist, XYZ Healthcare Inc., 2011 – 2014
- Identified discrepancies between medical records and codes, while ensuring accuracy and compliance
- Audited medical charts, noted issues, and communicated with physicians to resolve discrepancies
- Reviewed and updated medical records, ICD- 10 codes, and other documentation
- Developed coding and documentation standards, procedures, and processes
- Trained and educated staff on coding best practices
Education:
Bachelor of Science in Health Care Administration, ABC University, 2011
Clinical Documentation Improvement Specialist Resume with No Experience
A recent college graduate with a degree in Health Care Administration eager to leverage education and skills to help a health care organization achieve their goals and objectives as a Clinical Documentation Improvement Specialist.
Skills:
- Knowledgeable in ICD- 10 Code, Clinical Documentation Improvement, Medical Terminology, and CPT Coding
- Proficient in Microsoft Office Suite and Electronic Medical Record Systems
- Excellent communication and organizational skills
- Detail- oriented and highly organized
- Ability to multitask and handle multiple projects simultaneously
Responsibilities:
- Assist healthcare providers in obtaining accurate and complete medical documentation
- Utilize clinical knowledge and coding knowledge to ensure complete documentation
- Ensure accuracy of documentation to ensure proper reimbursement of services
- Monitor documentation and provide feedback to providers on any discrepancies
- Educate clinicians on proper documentation practices and coding rules
- Collaborate with interdisciplinary team to ensure accuracy of documentation
Experience
0 Years
Level
Junior
Education
Bachelor’s
Clinical Documentation Improvement Specialist Resume with 2 Years of Experience
A highly organized and motivated Clinical Documentation Improvement (CDI) specialist with two years of experience in healthcare. Possess excellent analytical and problem solving skills, with the ability to work independently or collaboratively in a team. Strong knowledge of ICD- 10- CM/PCS, CPT and HCPCS codes, as well as a commitment to achieving the highest quality of care.
Core Skills:
- Proficient in ICD- 10- CM/PCS, CPT and HCPCS codes
- Strong problem solving and organizational skills
- Excellent communication and interpersonal skills
- In- depth understanding of medical terminology, anatomy and physiology
- Ability to work independently or as part of a team
Responsibilities:
- Analyzing medical records and identifying areas of improvement
- Conducting reviews of patient records to ensure accuracy and compliance
- Providing guidance and education to physicians and clinical staff
- Developing comprehensive plans to improve medical documentation
- Collaborating with the medical community to ensure accurate documentation
- Assisting with the implementation of new clinical documentation systems and processes
- Reviewing and evaluating changes to coding regulations and guidelines
- Monitoring patient records for accuracy and completeness of documentation
- Assisting in the development of documentation improvement processes and protocols.
Experience
2+ Years
Level
Junior
Education
Bachelor’s
Clinical Documentation Improvement Specialist Resume with 5 Years of Experience
Experienced Clinical Documentation Improvement Specialist with 5+ years of experience in a healthcare setting. Skilled in analyzing medical records for accuracy and completeness of data. Committed to delivering quality results through the implementation of the latest technology and medical breakthroughs. Possess excellent communication and problem- solving skills, as well as a strong ability to collaborate with medical staff and healthcare administrators.
Core Skills:
- Expert in medical terminology
- In- depth knowledge of ICD- 10 and CPT coding
- Highly proficient with EHR systems
- Excellent communication and interpersonal skills
- Strong organizational and problem- solving skills
- Ability to work independently and as part of a team
Responsibilities:
- Assess and analyze medical records for accuracy and completion of data
- Review documents for inconsistencies and identify areas for improvement
- Develop and implement strategies to ensure accurate completion of patient records
- Monitor trends in coding and documentation compliance
- Develop and provide education and training to medical staff on documentation improvement
- Collaborate with healthcare teams to ensure proper documentation of patient care
- Manage and analyze data from CDI audits to ensure quality results
Experience
5+ Years
Level
Senior
Education
Bachelor’s
Clinical Documentation Improvement Specialist Resume with 7 Years of Experience
Highly experienced, organized, and dedicated Clinical Documentation Improvement Specialist with seven years of experience in the healthcare industry. Adept in researching and analyzing patient records for accuracy, evaluating physician documentation for proper coding, and ensuring comprehensive data reporting. Experienced in performing concurrent and retrospective reviews, providing clinical education, and working with interdisciplinary teams to ensure highest standards of care. A focused and hardworking professional with a knack for problem- solving and excellent leadership skills.
Core Skills:
- Record Research and Analysis
- Coding Evaluation
- Clinical Documentation and Coding
- Interdisciplinary Team Coordination
- Quality Assurance and Reporting
- Medical Terminology and Concepts
- Problem Analysis and Resolution
- Communication and Interpersonal Skills
- Time Management and Organization
Responsibilities:
- Reviewed medical documents to ensure accuracy and completeness of documentation, while adhering to regulatory requirements.
- Ensured proper coding by evaluating physician documentation and patient charts including diagnosis, procedure, and services.
- Performed concurrent and retrospective reviews, identified deficiencies, and provided clinical education to physicians to improve and enhance documentation.
- Maintained awareness of coding trends and changes, providing up- to- date information to members of the interdisciplinary team.
- Assisted in the development and implementation of clinical documentation improvement policies and procedures.
- Compiled and reviewed medical records according to established criteria to ensure accuracy, completeness, and compliance with regulatory standards.
- Researched and identified discrepancies between medical records and coding to ensure proper coding and reimbursement.
- Monitored clinical documentation and coding to ensure compliance and quality standards are met.
Experience
7+ Years
Level
Senior
Education
Bachelor’s
Clinical Documentation Improvement Specialist Resume with 10 Years of Experience
An experienced and certified Clinical Documentation Improvement (CDI) Specialist with 10 years of experience in analyzing patient medical records and providing quality assurance and accuracy of clinical documentation in the Electronic Health Records (EHR). Expertise in coding and documentation guidelines and principles, ICD- 10- CM, DRG and MS- DRG classifications. Skilled in managing multiple projects and ensuring compliance with HIPPA and other regulatory standards.
Core Skills:
- Coding and documentation guidelines
- Management of medical records
- Quality assurance
- Interpretation of medical terminology
- Regulatory standards compliance
- EHR and MS- DRG classifications
- ICD- 10- CM
- Analytical and problem- solving skills
- Leadership and team management
- Excellent organizational abilities
Responsibilities:
- Collaborated with physicians and other healthcare staff to ensure accurate and comprehensive documentation
- Assisted in the development and implementation of organizational policies/procedures related to clinical documentation
- Conducted medical record audits and maintained accurate documentation for all clinical activities
- Provided education and training to physicians and staff on coding and clinical documentation
- Maintained working knowledge of ICD- 10- CM, DRG and MS- DRG classifications
- Analyzed and reported clinical documentation improvement initiatives
- Identified and corrected errors in the medical records
- Monitored and reported on quality improvement initiatives
- Investigated and resolved coding and documentation discrepancies
Experience
10+ Years
Level
Senior Manager
Education
Master’s
Clinical Documentation Improvement Specialist Resume with 15 Years of Experience
A Clinical Documentation Improvement Specialist with 15 years of experience in improving the accuracy and completeness of medical records. Experience with coding, ICD- 10 and CPT standards, and other best practices to ensure accurate diagnosis and treatment. A detail- oriented problem- solver with excellent communication and organizational skills, and a passion for helping patients receive the best possible care.
Core Skills:
- Medical Coding
- ICD- 10 and CPT Standards
- Documentation Improvement
- Diagnosis and Treatment
- Organizational Skills
- Communication Skills
Responsibilities:
- Evaluate patient medical records to ensure the accuracy of diagnoses and treatments
- Identify discrepancies in the medical records and recommend revisions
- Coordinate with physicians and other healthcare staff to resolve discrepancies
- Develop and implement coding and documentation improvement initiatives
- Ensure compliance with all regulatory requirements
- Perform data analysis to identify gaps in medical records
- Provide coding and documentation education to staff
- Document all changes made to the medical record
Experience
15+ Years
Level
Director
Education
Master’s
In addition to this, be sure to check out our resume templates, resume formats, cover letter examples, job description, and career advice pages for more helpful tips and advice.
What should be included in a Clinical Documentation Improvement Specialist resume?
A Clinical Documentation Improvement Specialist is a highly qualified healthcare professional with expertise in medical coding and documentation. They help ensure accuracy and completeness of patient records, while also improving overall financial performance and patient care. If you’re looking to become a Clinical Documentation Improvement Specialist, make sure your resume is up to par. Here’s what should be included:
- Experienced in medical coding and documentation: Your resume should highlight your experience with medical coding and documentation. Include any experience you have with coding software, data entry, and reports.
- Knowledge of relevant regulations: Make sure to demonstrate your knowledge of relevant regulations, including HIPAA, ICD-10, and CMS regulations.
- Patient assessment skills: As a Clinical Documentation Improvement Specialist, you will be assessing patient progress and records on a daily basis. Make sure to highlight your patient assessment skills, such as your ability to evaluate patient records and determine the best course of action.
- Excellent organizational skills: Your resume should demonstrate your excellent organizational skills, with an emphasis on your ability to prioritize tasks and meet deadlines.
- Interpersonal skills: Clinical Documentation Improvement Specialists must be able to build relationships with staff and patients alike. Make sure to highlight your interpersonal skills, especially your ability to communicate effectively.
- Adaptability: Clinical Documentation Improvement Specialists must be able to adapt to changing situations and technologies. Demonstrate your adaptability by mentioning any experience you have with new software and systems.
By highlighting these key traits and experiences, your resume will be sure to stand out from the rest. A solid Clinical Documentation Improvement Specialist resume will open the door to a career in healthcare. Good luck!
What is a good summary for a Clinical Documentation Improvement Specialist resume?
A Clinical Documentation Improvement (CDI) Specialist is a healthcare professional responsible for ensuring that medical records accurately reflect patient care. A good summary for a Clinical Documentation Improvement Specialist resume should highlight the candidate’s experience in medical recordkeeping, knowledge of medical terminology, and ability to assess the accuracy of medical documentation. It should also showcase the candidate’s experience with medical coding, audit processes, and patient management. Additionally, the summary should emphasize the candidate’s proficiency with electronic health records systems and possess a keen understanding of HIPAA regulations. Furthermore, the summary should demonstrate the candidate’s exceptional communication and interpersonal skills in order to effectively work with healthcare providers and other stakeholders.
What is a good objective for a Clinical Documentation Improvement Specialist resume?
A Clinical Documentation Improvement Specialist (CDIS) resume should include a well-crafted objective that showcases the skills and experience of the individual applying for the position. A CDIS is responsible for helping healthcare providers improve the accuracy and completeness of medical documentation to ensure patient safety, quality of care, and reimbursement. An effective objective should be specific and demonstrate the applicant’s understanding of the job they are applying for.
Below are some examples of good objectives to include on a CDIS resume:
- Seeking a Clinical Documentation Improvement Specialist position that will allow me to leverage my experience in healthcare documentation and coding to ensure patient safety and quality of care.
- Experienced healthcare clinician and coder looking for a position as a Clinical Documentation Improvement Specialist, where I can use my knowledge and expertise to help healthcare providers improve the accuracy and completeness of medical documentation.
- Looking for a Clinical Documentation Improvement Specialist position to utilize my strong communication and documentation skills to help ensure that patient safety and quality of care are always maintained.
- Seeking a Clinical Documentation Improvement Specialist position to help healthcare providers improve the accuracy and completeness of medical documentation in order to ensure patient safety, quality of care, and timely reimbursement.
How do you list Clinical Documentation Improvement Specialist skills on a resume?
A Clinical Documentation Improvement Specialist (CDIS) is a highly trained professional who specializes in improving the accuracy of patient medical records and providing guidance to healthcare providers on better documentation practices. When listing your CDIS skills on a resume, it’s important to include the following:
- Extensive knowledge of ICD-10-CM and MS-DRG coding systems and the ability to interpret and apply them accurately
- Ability to review and analyze clinical documentation and medical records for accuracy and completeness
- Knowledge of reimbursement regulations and their impact on documentation accuracy
- Excellent communication and interpersonal skills when working with physicians, nurses and other healthcare staff
- Ability to work with EMR and other computer systems
- Ability to teach and train healthcare providers in more effective medical documentation practices
- Ability to develop and implement documentation improvement initiatives
- Proficiency in medical terminology and abbreviations
- Ability to identify documentation issues and develop improvement plans
- Understanding of Medicare and Medicaid regulations, including Quality Measures
- Knowledge of documentation improvement software and systems
What skills should I put on my resume for Clinical Documentation Improvement Specialist?
As a Clinical Documentation Improvement Specialist, you need to be able to identify and document medical conditions, treatments, and other data elements accurately and efficiently. Your resume should reflect your technical knowledge and any other core skills that you possess. Below are some of the key skills that should be highlighted on your resume:
- Knowledge of medical terminology and coding systems: As a Clinical Documentation Improvement Specialist, you need to be familiar with common medical terminology and coding systems such as ICD-10, CPT, and HCPCS. You should also have a good understanding of the various rules and regulations governing medical documentation such as HIPAA and other privacy laws.
- Excellent communication skills: You need to have strong verbal and written communication skills to be able to effectively communicate with medical professionals and other staff. You should also be able to explain complex medical documents and medical terms in simple terms to patients and their families.
- Attention to detail: A Clinical Documentation Improvement Specialist must be detail-oriented and have the ability to accurately review, analyze, and interpret medical records. You should have a keen eye for mistakes and be able to recognize errors and inconsistencies in documentation.
- Organizational skills: As a Clinical Documentation Improvement Specialist, you need to be able to effectively organize and prioritize tasks. You should have strong organizational skills to ensure that all documentation is completed accurately and on time.
- Computer skills: You need to have a working knowledge of computers, software programs, and databases in order to effectively use electronic health records (EHRs). You should also have the ability to quickly enter data and retrieve information from EHRs.
By highlighting these important skills on your resume, you can demonstrate to potential employers that you have the necessary knowledge and abilities to be a successful Clinical Documentation Improvement Specialist.
Key takeaways for an Clinical Documentation Improvement Specialist resume
As a Clinical Documentation Improvement Specialist, you play an important role in ensuring that patient medical records and documents are accurate and complete. When crafting your resume, it’s important to highlight this important skill and demonstrate how you can continue to improve the accuracy and completeness of patient records. Here are some key takeaways to keep in mind when writing your resume:
- Focus on Your Professional Experience: Your professional experience as a Clinical Documentation Improvement Specialist should be the focus of your resume. Emphasize the work you’ve done managing patient records and documents, as well as any other duties you may have performed in your role.
- Highlight Your Technical Skills: Clinical Documentation Improvement Specialists need to have a good understanding of medical coding and terminology. Make sure to highlight any technical skills that you possess, such as your familiarity with coding systems and medical vocabulary, as well as any software you may be proficient in.
- Demonstrate Your People Skills: As a Clinical Documentation Improvement Specialist, you’ll need to work closely with other staff members, so make sure to include any people skills you may have developed in your role. Highlight any experience you have working in a team, as well as any customer service skills you may have learned.
- Show Your Analytical Abilities: Clinical Documentation Improvement Specialists must be able to quickly analyze large amounts of data and identify discrepancies in patient records. Make sure to mention any experience you have in this area, as well as any analytical techniques you may be familiar with.
By emphasizing these key takeaways in your resume, you’ll be able to show potential employers that you’re an experienced and knowledgeable Clinical Documentation Improvement Specialist.
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