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Skills

  • Patient chart auditing ability
  • Adept multi-tasker
  • ICD-10 and CPT coding knowledge
  • Accurate medication and allergy record-keeping
  • Records maintenance professional
  • Research and Data Analysis
  • Clear and effective communication with clinical staff
  • Healthcare regulatory compliance
  • Initiating follow-ups on outstanding orders
  • Detailed assembly of physician notes for legal compliance

Work Experiences

  • Collaborated with medical coders.
  • Completed and reviewed 5 templated charts per shift to ensure critical patient information was recognized and thoroughly documented before physicians signed off.
  • Collaborated with medical coders to ensure medical diagnoses and procedures were appropriately documented, achieving a 18% reduction in claim denials related to incomplete documentation.
  • Compiled physician notes on 12 patient cases monthly.
  • Aided in swift patient care execution.
  • Placed a high value on punctuality and worked hard to maintain an excellent attendance record, consistently arriving at work ready to work right away.
  • Looked for industry trends on social media and through online sources.
  • Aided in real-time electronic documentation of resuscitations.
  • Edited speech recognition software-generated drafts.
  • Completed 14-hour training in 2019.

Summaries

  • Captured clinical notes effectively.
  • Adept in managing diagnostic test follow-ups using Power BI, significantly reducing delays in care by 18 days and improving timely patient treatment and management.
  • Achieved 61% improved documentation efficiency.
  • Captured key patient information.
  • Excellent judgment and reasoning skills have been demonstrated in the past.
  • Collaborated with physicians.
  • Accurate and detail-oriented Scribe.
  • Committed to accurate medical terminology.
  • Captured critical medication and lab results.
  • Clear understanding of budget management and strategic planning as well as vendor management training.

Accomplishments

  • Effectively maintained a database of medical records for 4 cases per month while adhering to strict regulatory guidelines.
  • Maintained detailed records for over 17 patient cases per shift, ensuring accuracy and compliance with HIPAA regulations.
  • Developed and implemented quick-reference guides for common medical terms and abbreviations used in the ED, reducing documentation handling time by 21%.
  • Coordinated with emergency department (ED) physicians to provide real-time dictation with 33% adherence to medical documentation protocols.
  • Updated physician-dictated records on system for 13 patient charts per shift, ensuring accurate billing and insurance claims.
  • Utilized metric to enter critical patient information, maintaining a near-perfect data entry accuracy rating of 74%.
  • Used Microsoft Excel to develop inventory tracking spreadsheets.
  • Trained incoming ED scribes on best practices for efficient real-time documentation, aiding in a departmental productivity increase of 33%.
  • Documented and resolved method which led to procedure.
  • Consistently met or exceeded the department's target for chart accuracy, reducing physician revision workload by 84%.

Affiliations

  • Collaborator in Trauma Informed Care Initiatives, procedure
  • Team Participant, Stroke Protocol Improvement Committee 2015
  • National Association of Medical Scribes (NAMS)
  • American Medical Informatics Association
  • Advanced Practitioner Society for Hematology and Oncology (APSHO)
  • National Association for Healthcare Quality (NAHQ)
  • Medical Scribe Professionals Network
  • Association of Information Technology Professionals
  • Health Information and Management Systems Society (HIMSS)
  • International Association of Scribes and Clerical Professionals (IASC)

Certifications

  • Apple Certified Associate (ACA)
  • Professional Medical Scribe Certification (PMSC) by Berkeley College
  • Certified Medical Transcriptionist (CMT)
  • CompTIA A+ Technician
  • Certified Healthcare Risk Management (CHRM) by American Society for Healthcare Risk Management (ASHRM)
  • Certified Medical Administration Assistant (CMAA) by NHA
  • Basic Life Support (BLS) Certification
  • Cisco Certified Network Associate (CCNA)
  • Certified Public Accountant (CPA)
  • Trauma Nursing Core Course (TNCC) Certification

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