Well-trained Clinical Documentation Specialist skilled in medical terms, coding and working with talented teams. Focused professional with expertise assessing and auditing medical records for review of physician accuracy and quality of care. Ready for a new position in the medical field.
Skills
Clinical Documentation Review
Medical records review
Strong clinical judgment
Operational improvement creating job aids
Problem resolution
Team building and leadership
Organization
Interpersonal and written communication
Decision Making
Project organization
Data Entry
Outpatient Coding
Scheduling
Customer Service
Education
Excelsior CollegeNew York, NY, Expected in 2021 ā āAssociate:Nursing - GPA:
In progress
Concorde Career CollegeGrand Prairie, TX, Expected in 2016 ā āVocational Nursing Diploma:Nursing - GPA:
Reviewed 30-50 electronic clinical documents from pharmacy's, physician offices and health insurance appeals daily to determine if any adverse events from specialty medical medications occurred.
Experience writing clinical quality narratives auditing for individual drug safety reports.
Assisted with medical utilization review of clinical documentation to identify approval or denial of medical necessity criteria of specialty medications.
Transcribed calls between patient's and case managers to provide to client for review.
Demonstrated knowledge of safety concepts, global regulatory reporting obligations.
Worked with multidisciplinary team to carry out assignments and projects.
Worked effectively within healthcare teams on successful audits and quality initiatives.
Audited charts and reviewed clinical documents to verify accuracy.
Carefully reviewed patient files for clarity on diseases, diagnoses and procedures to determine quality of care.
Managed electronic clinical documentation and uploaded changes or updates using multiple systems.
Maintained strong knowledge of medical terminology, diseases and conditions and procedures.
Identifies new methods to optimize medical records management.
Managed quality assurance program, including on-site evaluations, internal audits.
HIGHLAND SPRINGS - LVN-Post Acute City, STATE, 07/2019 - 04/2020
Worked as needed with multidisciplinary team to carry out successful medical treatment plans for diverse acute and chronic conditions.
Responded to patient requests with appropriate clinical and personal assistance.
Assessed 7-14 patients' temperature, pulse and blood pressure and recorded in electronic medical records.
Delivered oral medications, intramuscular injections and IV fluids to mitigate or resolve patient symptoms.
Managed various general office duties such as answering multiple telephone lines, completing insurance forms and mailing monthly invoice statements to patients.
Protected patients and healthcare team members from infection by sterilizing equipment and reusable supplies.
Reviewed patient history to verify conditions and current medications.
Circulated assigned floor to measure and record patients' fluid and food levels, implementing measures to promote healthy intake and output as necessary.
Documented patient information obtained from interviews concerning symptoms, medications and prior treatment.
Clearly and thoroughly explained diagnoses, treatment options and procedures to patients and loved ones, checking in to verify understanding.
Sono Bello - Outpatient Surgical Nurse City, STATE, 03/2017 - 12/2017
Circulated within operating room.
Providing observations of patient's vital signs and providing intervention.
Stocked exam rooms and operating room as needed.
Ordered office and surgical supplies.
Utilized autoclave daily and maintained strict sterile technique.
Created warm, supportive atmosphere to keep patients feeling safe and comfortable immediately before and after surgery.
Educated family members and caregivers on patient care instructions.
Audited charts and reviewed clinical documents to verify accuracy.
Educated patients and answered questions about health condition, prognosis and treatment.
Sustained quality standards by performing routine medication audits and upholding internal and industry best practices.
Updated patient charts using EHR with data such as medications to keep records current and support accurate treatments.
Accurately documented all elements of nursing assessment, including treatment, medications and IVs administered, discharge instructions and follow-up care.
Reported findings to quality departments after conducting routine restraint audits and worked with team to devise corrective actions for deficiencies.
Trained new nurses in proper techniques, care standards, operational procedures and safety protocols to optimize performance and safety.
Managed care from admission to discharge, including patient assessments, care planning, health educations and discharging support to provide comprehensive care to over 10 patients daily.
RAMBLING OAKS- REHABILITATION CENTER - LVN- Charge Nurse City, STATE, 08/2016 - 03/2017
Worked with multidisciplinary team to carry out successful treatment plans for diverse acute and chronic conditions.
Responded to patient requests with appropriate clinical and personal assistance.
Helped long-term care residents with bathing, dressing, feeding and other daily living activities.
Assessed 14 patients' temperature, pulse and blood pressure and recorded in electronic medical records.
Managed various general office duties such as answering multiple telephone lines, completing insurance forms and mailing monthly invoice statements to patients.
Protected patients and healthcare team members from infection by sterilizing equipment and reusable supplies.
Took samples such as blood and urine to complete diagnostic and routine assessment tests.
Documented patient vitals, behaviors and conditions to communicate concerns to supervising nurse.
Reviewed patient history to verify conditions and current medications.
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