Zubair Anwar , MD MPH CDIP
Sacramento
Summary
Seasoned Clinical Documentation Specialist with a robust background in enhancing medical record accuracy and compliance, notably at Prime Healthcare Services. Expert in EHR systems and possesses a keen attention to detail. Proven track record in improving documentation quality by over 30%, leveraging critical thinking and case management skills to optimize patient care and reimbursement processes.
Overview
9
9
years of professional experience
1
1
Certification
Work History
Clinical Documentation Specialist
Prime Healthcare Services
07.2023 - Current
- Conduct thorough reviews of clinical documentation to ensure accuracy, completeness, and compliance with ICD-10 Coding guidelines.
- Navigate and utilize Meditech and Epic electronic health record system.
- Conducted comprehensive reviews of inpatient medical records to ensure clinical documentation accurately reflected patient diagnoses, treatments, and outcomes.
- Collaborated with physicians, nursing staff, and other healthcare providers to clarify and improve clinical documentation for accurate coding and optimal reimbursement.
- Performed concurrent and retrospective chart reviews to assess the accuracy, completeness, and specificity of documentation in alignment with coding guidelines and regulatory requirements.
- Ensured documentation met standards for patient safety, quality of care, and compliance with Medicare and other regulatory bodies.
- Identified opportunities for documentation improvement and provided education and guidance to healthcare providers on proper documentation practices.
- Facilitated communication between clinical staff and coding professionals to ensure consistency and accuracy in medical record documentation.
- Participated in regular case discussions and interdisciplinary meetings to support accurate and timely documentation of patient care.
- Monitored and tracked documentation trends, providing feedback to the healthcare team to enhance overall documentation quality and compliance.
Research With Global Immunization Action Network
GIANT
05.2023 - Current
- Research and report on hepatitis A outbreaks in the United States.
- Coordinate stakeholder meetings to engage the communities
- Submission of grant proposals
Internship Student
California Department Of Public Health
09.2023 - 12.2023
- Ensure a high standard of Public health protection for medical devices in California
- Data Analysis and visualization using python
Clinical Documentation Specialist
Shifa Community Clinic
08.2021 - 07.2022
- Conducted concurrent and retrospective reviews of inpatient medical records to ensure clinical documentation accurately reflects quality of care and compliance with reimbursement guidelines.
- Collaborated closely with medical staff to facilitate appropriate and thorough clinical documentation for patient care.
- Conducted documentation assessments for inpatient admission criteria and performed initial and extended-stay concurrent reviews on selected admissions.
- Documented findings and provided feedback to healthcare providers to enhance the accuracy and completeness of clinical documentation.
- Ensured compliance with acute care service standards, contributing to improved patient outcomes and optimized reimbursement processes.
Medical Doctor
Victoria Hospital
09.2015 - 10.2020
- Maintained accurate and up-to-date medical records, documenting patient histories, examinations, diagnoses, treatments, and outcomes.
- Conducted physical examinations, made diagnosis, and provided treatment
- Assisted in managing and coordinating patient care and treatment .
- Administer a high level of care to patient,through active listening, open ended questioning.
- Experience in performing preoperative assessments and post operative follow up.
- Diagnosed and treated patients with a variety of complex medical conditions, including sepsis, pneumonia.
Education
Master of public health -
University of San Francisco (USF)
2024
MBBS - Medicine
Xian Jiaotong University
2015
Skills
- Attention to details
- In-depth understanding of disease Pathology & Physiology
- Bedside care
- EHR systems
- Microsoft Office & Excel
- Critical thinking
- Case management
Certification
CDIP- Certified Documentation Integrity Practitioner
CCS - Certified Coding Specialist
Timeline
Internship Student
California Department Of Public Health
09.2023 - 12.2023
Clinical Documentation Specialist
Prime Healthcare Services
07.2023 - Current
Research With Global Immunization Action Network
GIANT
05.2023 - Current
Clinical Documentation Specialist
Shifa Community Clinic
08.2021 - 07.2022
Medical Doctor
Victoria Hospital
09.2015 - 10.2020
MBBS - Medicine
Xian Jiaotong University
CDIP- Certified Documentation Integrity Practitioner
CCS - Certified Coding Specialist
Master of public health -
University of San Francisco (USF)
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