To ensure accuracy and compliance, I implement a multi-step review process, including regular audits, staff training, and the use of electronic health record (EHR) tools. I stay updated on regulatory requirements like HIPAA and CMS guidelines, ensuring documentation meets legal and organizational standards. Collaboration with clinicians and coders is key to address discrepancies and improve documentation quality.

When discrepancies arise, I first identify the root cause through thorough analysis and communication with the involved parties. I then work collaboratively with clinicians and coders to resolve inconsistencies, ensuring accurate and compliant documentation. I also document the corrective actions taken to prevent recurrence and provide feedback to improve future documentation practices.

I have extensive experience with EHR systems, including Epic, Cerner, and Meditech. I am proficient in utilizing these systems to streamline documentation processes, ensure data accuracy, and support compliance. I also train staff on EHR best practices and troubleshoot system-related issues to maintain workflow efficiency and documentation integrity.

I stay current by attending industry conferences, participating in webinars, and subscribing to regulatory updates from organizations like CMS and AHIMA. I also network with peers and join professional groups to share insights. Regularly reviewing and updating organizational policies ensures compliance with evolving regulations and best practices.

In a previous role, I identified inefficiencies in the documentation workflow and implemented a standardized template system within the EHR. This reduced errors, improved turnaround times, and enhanced compliance. I also conducted training sessions to ensure staff adoption, resulting in a 20% increase in documentation accuracy and a significant reduction in audit findings.