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Skill Highlights
  • Knowledgeable in medical vocabulary
  • Dependable
  • Computer proficient
  • Compassionate
 
 
  • Diligent and detail oriented
  • Quick learner
  • Supportive
  • Collaborative
Education and Training
Bachelor of Science: Biological Sciences, 2016 University of California Santa Barbara － Santa Barbara, CA, USA
Accomplishments
  • Dean's honor roll at Baylor University freshman year of college.
  • President's honor roll at Santa Barbara City College sophomore year of college.
Professional Experience
Trainer, 05/2018 to Current ScribeAmerica LLC － Plano, TX

I provide support, advice, and edit all the trainee's charts in real time during a training shift with the physician in a high-volume facility. I supervise the trainee throughout the entire shift and Tested trainees on materials to determine levels of understanding and areas requiring further instruction. I perform an in-depth evaluation on the trainee and discuss with my Head Trainer and Chief Scribe on trainee's performance. I complete 3 chart audits quarterly on all scribes on the team. I also attend a 1 hour meeting every month with the other trainers on my team to stay up to date and make any changes to our training techniques/reviews.
Emergency Department Scribe, 07/2017 to Current ScribeAmerica LLC － Plano, TX

I followed one physician throughout shift in high-volume, busy environments and documented details about patient histories, physical examinations, medications and other information into electronic charts. I used CareConnect medical record software every day and developed advanced skills. I received dictation and created high-quality documents. I maintained an understanding of all active patients in order to facilitate workflow with they physician.
Emergency Department Volunteer, 11/2015 to 12/2016 Santa Barbara Cottage Hospital － Santa Barbara, CA

Greeted visitors and established purpose of visit to complete check-in procedure quickly. I provided transportation of patient or visitor to other parts of the hospital as needed. I cleaned and prepared patient's rooms. I personally delivered blood work and other samples to the lab.
Personal Assistant, 06/2010 to 06/2016 Dr. Patricia Krakos － Plano, TX Worked part-time during high school and college. Helped with patient charting, computer entries, assisted dictating reports, condensing patient histories, and checked patient reports and charts for accuracy.
Physician Assistant Shadow, 06/2015 to 08/2015 Bent Tree Family Physicians － Frisco, TX Shadowed Sarah Gagliano, PA.  Took notes on diagnoses and patient examinations, as well as took blood pressure and listened to lung sounds occasionally.
Volunteer, 05/2015 to 07/2015 Texas Health Hospital of Plano － Plano, TX Assisted the front desk nurse on the telemetry floor by answering patient help-button calls, prepared new patient folders, and ran any necessary errands for the nurse on the floor.  Also worked at the main front desk of the hospital assisting people with directions and check in.
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Summary
Board Certified Internist , with experience in Primary Care and Urgent Care settings, comfortable with evaluating and treating patients of all ages
Skills
  • Comfortable with suturing , removing fish hooks, I and D and other minor office procedures
  • Certified department of transportation examiner
Experience
Staff Physician 11/2012 to Current Carwell Urgent Care South Dennis, MA Providing urgent Care services to people of all ages
Staff Physician 01/2008 to 01/2013 Mid Upper Cape Community Health Center Hyannis, MA Providing primary Care  to Adult medically underserved patients, as well as walk in care services as well
Staff Physician 05/1999 to 05/2007 Fontaine Medical Center Harwich, MA Providing Both acute and ongoing chronic care to adult patients
Staff Physician 02/1997 to 05/1999 Health Stop Hyannis, MA Providing acute and chronic medical care at a walk in facility
Staff Physician 08/1995 to 08/1997 Health America HMO Lebanon, PA Providing Primary Care as well as Hospital care to a medically underserved community, duties also included supervising family practice  residents of the Pennsylvania State University family Practice Residency Program.
Locum Tenens Physician 07/1992 to 07/1995 Comp Health
Physician Assistant 09/1982 to 06/1989 Montefiore Hospital Riker's Island Prison Health Services New York City, NY Providing Care to one of the largest Prison Populations in the United States, at the time this was the only JCAH accredited prison health care system in the country. 
Physician Assistant 02/1982 to 09/1982 Beth Israel Hospital New York City, NY Monitoring and Providing Health Care to opiate dependent individuals in a Methadone Maintenance Clinic
Education and Training
M.D.: Medicine 1989 State University Of New York at Stony Brook Stony Brook, New York Alpha Omega Alpha Honor Society
Physician Assistant 1982 Sophie Davis School of Biomedical Education New York City, New York
Medical College of VA Richmond , VA 1 Internship in Internal Medicine and Pediatrics
Medical College of VA Richmond, VA 1 Residency in Internal Medicine
Activities and Honors
Alpha Omega Alpha Honor Society
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Professional Summary
Dedicated Physician specializing in treating chronic ailments as well as acute conditions. Highly-motivated, team-oriented and compassionate Board Certified Family Practice Physician with years of direct  inpatient and outpatient experience.
Work History
Attending Physician, 06/2007 to Current
Maria Riza Bautista MD SC – 6307 South Stewart suite 202 Chicago Illinois 60621
  • Ordered and executed diagnostic tests and analyzed diagnostic images to further investigate patient conditions.
  • Appropriately diagnosed and treated a variety of diseases and injuries in a general practice setting.
  • Advised and educated patients regarding diet, hygiene and effective disease prevention methods.
Attending Physician, 06/2006 to 06/2007
Englewood Health Clinic – 6614 S.Halsted Street Chicago Illinois 60621
  • Discussed various treatment options with patients and families
  • Maintained accurate medical records and document patient history in the chart
  • Educate medical students in diagnosis and treatment plan 
Medical Provider, 03/2006 to 06/2006
Heartland Health Alliance – 1015 W.Lawrence Ave Chicago, Illinois 60640
  • Examined patients and provide treatment plan
  • Coordinate with other healthcare professionals in treatment plan 
Phlebotomist/Laboratory Assistant, 01/2001 to 01/2002
Swedish Covenant Hospital – 5145 N. California ave. Chicago, Illinois 60625
  • Collect specimen from patients and assist in processing tests
Surgical Assistant, 06/1998 to 06/1999
St.Elizabeth Hospital
  • Assisted in all types of General Surgery
  • Responsible for patient admissions and procedure preparation
Education
Family Practice Residency: 2006
Jackson Park Hospital - Chicago, Illinois
Medical Externship: 1997
Medical City Hospital - Manila, Philippines
M.D.: 1995
University of the East Ramon Magsaysay Medical Center - Manila, Philippines
Affiliations
  • Advocate Illinois Masonic Hospital
  • Kindred Hospital
  • Norwegian American Hospital
  • St.Bernard Hospital
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Career Objective

Proficient Clinical Documentation Improvement Specialist and Foreign Medical Graduate, looking for
opportunity to use my knowledge, skills and experience to coordinate Health Information Management (HIM) Programs which includes CDI program. Brings valuable knowledge, and work experience as an inpatient concurrent and retrospective review CDI Specialist. Solid background in Inpatient & Outpatient documentation abstraction and review in an acute care setting; coding and billing experience in Physician clinics; well-grounded in one-on-one,  and group physician education for documentation improvement. Committed, in assuring improved hospital CMI by accurate capturing of CC/MCC, and optimizing DRG/APR for all payers.

Skills
  • Extensive knowledge of sound documentation guidelines and standards for medical practice
  • Skilled in drafting clinical reports and presentations
  • Vast working experience in a HIM managerial position
  • Profound knowledge of Health Information Administration
  • Proficient with revenue cycle operations Familiarity with Health Information Management
  • Ability to handle multi tasks
  • Ability to communicate effectively
  •  Excellent computer skills such as Microsoft word, Excel, PowerPoint, PowerPC, 3M Encoder, CAC, Werner, Epic application, 3M 360 etc.
  • Skilled in drafting clinical reports and presentations Ability to maintain confidentiality of patients' information ICD-10 coding, MS-DRG/APR-DRG assignment CPT/ HCPCS Coding for out-patient
Experience
Field /Clinical Documentation Nurse-Epic Health | Houston, TX Clinical Documentation Specialist 01/2014 - 12/2018
  • Provides face-to-face educational opportunities with physicians on a daily basis
  • Provides complete follow through on all requests for clarification or recommendations for improvement
  • Leads the development and execution of physician education strategies resulting in improved clinical documentation
  • Provides timely feedback to providers regarding clinical documentation opportunities for improvement and successes
  • Ensures effective utilization of CAC for chart review and electronic query clarification.
  • Proactively develops a reciprocal relationship with the HIM Coding Professionals
  • Coordinates and conducts regular meeting with HIM Coding Professionals to reconsolidate DRGs, monitor retrospective query rates and discuss questions related to Coding and CDI
  • Engages and consults with Physician Advisor /VPMA when needed, per the escalation process, to resolve provider issues regarding answering clarifications and participation in the clinical documentation improvement process
  • Actively engages with Care Coordination and the Quality Management teams to continually evaluate and spearhead CDI opportunities
Sydney's Place | Viacell-Sugarland, TX Clinical Documentation Specialist 03/2014 - 09/2014
  • A management-consulting firm providing business development and improvement solutions to the healthcare system.
  • Interfaced, Managed, and assisted physicians to enter orders from EHR/HIS or via a web page and send those orders directly to diagnostic services systems (RIS/PACS systems).
  • Managed orders for different modalities and procedures, e.g. General radiology test, Nuclear Medicine test, MRIs, and CT scans.
  • Interfaced and provided the ability to produce medication schedules automatically based on predefined unit specific or medication specific schedules.
  • Provided ability to enter dosage and have system calculate IV drip rate based on concentration and tubing drip factor.
  • Provided ability to forward, as appropriate, information to flow sheet of any discipline (PT, RT, dietary, lab, etc). Also, automatically flag medications that are due to expire within specified time period as defined by the hospital.
Medical Group/San Bernardino Community Hospital | San Bernardino, CA Clinical Documentation Specialist 01/2010 - 12/2010
  • Perform a thorough concurrent in-patient chart review to identify gap process for documentation improvement.
  • Review charts to assign Initial DRG, query physicians for specificity, acuity, for clinical validation, uncertain diagnosis and conflicting documentation.
  • Ability to identify MCCs/CCs for DRG improvement, SOI/ROM and for data quality.
  • Provides physician education for accurate specific clinical documentation to capture the Severity of illness, risk of mortality and accurate reimbursement.
  • Member of Utilization management, quality and denial committee.
  • Managed functions performed by the HIM department.
  • Provided effective financial management & efficient use of resources.
  • Provided strategic planning & direction for development & enhancement of health information related services.
  • Ensured that goals & services provided by HIM were aligned w/ organization priorities.
Abia State University | Uturu, Imo-state Internal Medicine Attending Physician 02/2005 - 12/2009
  • Provide and manage direct patient care, including physical examinations, evaluations, assessments, diagnoses, and treatment.
  • Train and supervise residents and on-call residents engaged in specialty activities and procedures, including emergency room on-call duties, inpatient area, outpatient clinic, nursing home/rehabilitation and long-term care/hospice unit, and off-site outpatient clinics.
  • Effectively manage ER, medical floor inpatients, emergencies in ICU/CCU, and all in-house medical residents while on call as attending Medical Officer of the day.
  • Frequently function as acting Chief Resident, directing and coordinating the patient care activities of nursing and support staff. Collaborate with residents on Internal Medicine Residency Program
Education and Certification
Abia State University | Uturu-Nigeria M.D. in Medicine and Surgery 2003
United State Medical and licensing Exam Educational Commission for Foreign Medical Graduate Certification 2012
Licensed Vocational Nurse Certificate | Houston, TX 2014
Certified Coding Certificate (CCS) AHIMA 2019
Activities and Honors

Employee recognition awards: 

Employee recognition collaboration award for physician engagement 

Teamplayer:  Execellent relationship with co-workers and Coders.

ACDIS and AHIMA member for CEUs

Involved in monthly CDI webex and bi-weekly huddles



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