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Jessica Claire
  • Montgomery Street, San Francisco, CA 94105
  • Home: (555) 432-1000
  • Cell:
  • resumesample@example.com
Summary

Well-trained Clinical Documentation Specialist skilled in medical terms, coding and working with talented teams. Focused professional with expertise assessing medical records for review of physician accuracy and quality of care. Ready for a new position in the medical field.

Skills
  • Documentation improvement
  • Healthcare staff interaction
  • Report creation
  • Clinical documentation oversight
  • Skilled in MediTech, 3M Coding, and Docuaide
  • Accurate record reviews
  • Communications
Experience
Clinical Documentation Specialist, 06/2014 to Current
Northwestern MedicineSandwich, IL,
  • Acquired strong background in medical terms, illnesses and conditions and medical procedures.
  • Uncovered discrepancies in health records and contacted physicians to provide further documentation to clarify concerns.
  • Explained to entire healthcare team importance of providing in-depth, accurate medical records and documentation
  • Created agendas and communication materials for team meetings.
  • Investigated rejected and denied claims, working with coders to formulate denial letter responses/findings for appeals.
  • Entered patient health information into software and confirmed records.
  • Collaborated with others to discuss new query opportunities.
  • Worked closely with team members to discuss coding requirements, develop queries and educate on coding changes and specificity.
Registered Nurse (Outpatient Surgery), 07/2001 to 06/2014
Chi HealthSignal Mountain, TN,
  • Oversaw patient admission and discharge processes to coordinate efficient plans of care.
  • Monitored and recorded patient condition, vital signs, recovery progress and medication side effects.
  • Administered medications, tracked dosages and documented patient conditions.
  • Coordinated care with physicians and other clinical staff to prepare for treatment, carry out interventions and enhance continuum of care to deliver comprehensive services.
  • Helped pediatric patients understand and feel at ease with tests and minor procedures.
  • Maintained personal and team compliance with medication administration standards and patient care best practices.
  • Updated physicians on patient test results and assisted in developing care plans.
  • Administered scheduled medications and therapies intravenously, rectally, orally, subcutaneously and via intramuscular injections while overseeing pain management plans.
  • Assisted patients with healing and recovery after surgery by closely monitoring and caring for wounds, answering questions and educating about continued care strategies.
  • Instructed patients, caregivers and families on diagnoses, treatment options and self-management to maintain continuity of care.
  • Delivered information regarding care and medications to patients and caregivers in comprehendible terminology.
  • Participated in continuing education programs and gastroenterology workshops to enhance training and nursing knowledge.
  • Assessed patient conditions, monitored behaviors and updated supervising physicians with observations and concerns.
  • Administered oral, intramuscular and IV medications to patients and monitored responses.
Medical/Surgical Nurse, 03/2000 to 07/2001
Putnam General HospitalCity, STATE,
  • Oversaw treatments, therapies and medication administration according to prescribed methods and protocols.
  • Educated patients and families on diseases, medical and surgical procedures, medication regimens and pain self-management.
  • Performed comprehensive patient assessments to identify patient needs, devise individualized plans of care, modify care solutions and ensure patients' rights.
  • Delivered tailored nursing care to adult patients suffering from multiple diagnoses.
  • Participated in discussions with healthcare team members regarding surgical patients to address and resolve concerns.
  • Pitched in to assist with nursing duties in areas where healthcare teams were short-staffed.
  • Oversaw safety and compliance with patient confidentiality requirements.
  • Collaborated with multidisciplinary healthcare professionals to administer therapies and maintain continuum of care.
  • Carried out nursing tasks safely to maintain high level of care that complied with organization's procedures and regulations.
  • Coordinated with healthcare team to establish, enact and evaluate patient care plans.
  • Coordinated care with physicians and other clinical staff to prepare for treatment, carry out interventions and enhance continuum of care to deliver comprehensive services.
  • Conducted patient assessments and diagnostic tests to provide physician with important patient health information.
  • Delivered quality patient care from admission to discharge through direct supervision of all nursing and ancillary staff.
Registered Nurse-Cardiac Floor, 10/1999 to 03/2000
CAMC MemorialCity, STATE,
  • Acquired strong background in medical terms, illnesses and conditions and medical procedures.
  • Determined quality of care provided to patients through careful assessment of medical documentation.
  • Completed complete assessments of patients following cardiac surgery/procedures and reported any abnormal findings or concerns to physicians/mid level practitioner.
  • Administered treatments and medications appropriately to patients as ordered.
  • Educated families and patients on new diagnoses, treatments, and medications as directed by physicians.
Education and Training
Associate of Nursing: Nursing, Expected in 05/1999
Kettering College of Medical Arts - Kettering, Ohio,
GPA:
: Pre-Nursing, Expected in
Marshall University - Huntington, WV,
GPA:
High School Diploma: , Expected in 06/1993
Buffalo High School - Buffalo, WV,
GPA:

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Resume Overview

School Attended

  • Kettering College of Medical Arts
  • Marshall University
  • Buffalo High School

Job Titles Held:

  • Clinical Documentation Specialist
  • Registered Nurse (Outpatient Surgery)
  • Medical/Surgical Nurse
  • Registered Nurse-Cardiac Floor

Degrees

  • Associate of Nursing
  • Some College (No Degree)
  • High School Diploma

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