RN/ Clinical Documentation Integrity Specialist Resume Example Company Name

RN/ CLINICAL DOCUMENTATION INTEGRITY SPECIALIST

Summary

20 year Registered Nurse with experience in Critical Care and management skills. Excellent critical thinking skills, ability to work autonomously, and multitask. Proficient in interpersonal relationships/ collaboration with the Interdisciplinary team approach to provide safe, effective, quality care.. I feel that my experience and skills will serve to be a great asset to your TEAM!

Skills

*Proficient with review of medical terminology and DRG assignment

*Current and continual knowledge/inservice for Medicare CMS Guidelines

*Knowledge and experience with Core Measure extractions

* Collaborate Monthly online/ phone meetings with Remote Coders to discuss topics of concerns/ process improvements

*Participation in Interdisciplinary Team approach for improved quality of care

* Professional skills in Physician relations with face to face, phone or e-mail correspondence

*Professional creativity/educational opportunities for Physician engagement

*Proficient with "critical" thinking skills which allow me to be a great patient advocate

Experience

RN/ Clinical Documentation Integrity SpecialistCompany Name | City, State | October 2013 - Current

Worked closely with team members to deliver project requirements, develop solutions and meet deadlines.
Escalated identified risk issues, challenges and trends to senior management and delivered risk-related documents for audit and regulatory exams.
Maintained industry knowledge through continuing education, training and monitoring of industry publications.
Performed site evaluations, customer surveys and team audits as part of quality assurance program.
Implemented, maintained and verified compliance to various international quality standards and administered training on standards.
Created agenda, materials and communications for team meetings.

RN/Clinic Nurse ManagerCompany Name | City, State | April 2009 - September 2013

Monitored post-op vitals, set up PCA, fluids, reviewed post-op orders and assimilated patients to unit.
Treated patients using pharmacological and non-pharmacological treatment modalities to address various disorders, diseases and injuries.
Monitored diet, physical activity, behaviors and other patient factors to assess conditions and adjust treatment plans.
Communicated with primary care physicians or emergency care providers to relay patient needs.
Administered oral, IV and intra-muscular medications and monitored patient reactions.
Maintained infection control logs, streamlined charting process, and improved patient outcomes through training and leadership.
Executed appropriate steps for patient treatment following careful review of physician medical regimen.
Managed and provided leadership to help staff with direct and indirect patient care and telemetry monitoring.
Consistently maintained core measures, patient satisfaction and HCAPs above 85%.
Addressed unit staff concerns, including staffing ratios, resource management, allocation of responsibilities and optimized workload management.
Assessed patient conditions, monitored behaviors and updated supervising physicians with observations and concerns.
Participated in continuing education programs and workshops to enhance training and nursing knowledge.
Maintained strict patient data procedures to comply with HIPAA laws and prevent information breaches.
Coordinated care with physicians and other clinical staff to prepare for treatment, carry out interventions and enhance continuum of care to deliver comprehensive services.
Developed and maintained quality care systems and standards, including creating and improving medical protocols and guidelines.
Immunized patients against diseases such as influenza and pneumonia to protect vulnerable populations from serious illnesses.
Provided training and supervision to 12-member staff in Dialysis unit.
Ensured quality patient care from admission to discharge through direct supervision of all nursing and ancillary staff.
Observed strict safety measures, including checking medication dosages before administration to patients.
Responded to emergency situations with speed, expertise and level-headed approaches to provide optimal care, support and life-saving interventions.
Monitored and recorded patient condition, vital signs, recovery progress and medication side effects.
Used facility EMR system to update patient records, transmit prescriptions and transfer files.
Delivered information regarding care and medications to patients and caregivers in comprehendible terminology.
Answered patient questions and provided take-home materials for further information.
Inserted and managed central, arterial and PICC lines.
Utilized computerized Resource and Patient Management System (RPMS) and Electronic Health Record (EHR) system.
Trained and mentored new RNs on best practices, hospital policies and standards of care.
Conducted patient assessments and diagnostic tests to provide physician with important patient health information used to create focused treatment plans and manage ongoing care.
Delivered quality care and comfort to patients with heart failure, pulmonary hypertension, pulmonary embolisms and end-stage renal disease.
Coordinated with healthcare team to establish, enact and evaluate patient care plans.
Developed and adapted individualized treatment plans according to patient recovery goals.

RN Staff NurseCompany Name | City, State | November 2006 - October 2008

Conducted patient assessments and diagnostic tests to provide physician with important patient health information used to create focused treatment plans and manage ongoing care.
Immunized patients against diseases such as influenza and pneumonia to protect vulnerable populations from serious illnesses.
Inserted and managed central, arterial and PICC lines.
Maintained adequate unit supplies to meet expected patient demands.
Treated patients using pharmacological and non-pharmacological treatment modalities to address various disorders, diseases and injuries.
Treated patients by administering various types of medications and therapies.
Administered oral, IV and intra-muscular medications and monitored patient reactions.
Observed strict safety measures, including checking medication dosages before administration to patients.
Helped patients and families feel comfortable during challenging and stressful situations, promoting recovery and reducing compliance issues.
Developed and adapted individualized treatment plans according to patient recovery goals.
Used facility EMR system to update patient records, transmit prescriptions and transfer files.
Delivered quality care and comfort to patients with heart failure, pulmonary hypertension, pulmonary embolisms and end-stage renal disease.
Administered oral, intramuscular and IV medications to patients and monitored responses.
Managed and provided leadership to help staff with direct and indirect patient care and telemetry monitoring.
Addressed unit staff concerns, including staffing ratios, resource management, allocation of responsibilities and optimized workload management.
Trained and mentored new RNs on best practices, hospital policies and standards of care.
Counseled patients and caregivers, providing emotional, psychological and spiritual support.
Maintained infection control logs, streamlined charting process, and improved patient outcomes through training and leadership.
Assessed patient conditions, monitored behaviors and updated supervising physicians with observations and concerns.
Coordinated care with physicians and other clinical staff to prepare for treatment, carry out interventions and enhance continuum of care to deliver comprehensive services.
Responded to emergency situations with speed, expertise and level-headed approaches to provide optimal care, support and life-saving interventions.
Monitored and recorded patient condition, vital signs, recovery progress and medication side effects.
Executed appropriate steps for patient treatment following careful review of physician medical regimen.
Ensured quality patient care from admission to discharge through direct supervision of all nursing and ancillary staff.
Developed and maintained quality care systems and standards, including creating and improving medical protocols and guidelines.
Communicated with primary care physicians or emergency care providers to relay patient needs.
Monitored diet, physical activity, behaviors and other patient factors to assess conditions and adjust treatment plans.
Maintained strict patient data procedures to comply with HIPAA laws and prevent information breaches.
Reached out to patients to convey lab results and provide care instructions.
Utilized computerized Resource and Patient Management System (RPMS) and Electronic Health Record (EHR) system.
Advocated for patient needs with interdisciplinary team and implemented outlined treatment plans.

RN/ICU Staff NurseCompany Name | City, State | June 1995 - February 2008

Worked with patients and their families to provide in-hospital and after-hospital follow-up through teaching and referral.
Identified problems, assisted in data gathering, proposed solutions and participated in evaluation of quality assurance issues.
Established and implemented nursing care plans for each patient through assessment, development, activation and evaluation.
Completed patient assessments, triaged and recorded patient histories, symptoms and observations.
Supported appropriate orientation, education, credentialing and continued professional development of associates.
Developed and maintained professional relationship with members of health care team, patient and patient's family.
Monitored patients' respiration activity, blood pressure and blood glucose levels in response to medical administration.
Performed nursing care following prescribed rules, policies, protocol and procedures.
Achieved best possible outcomes for nursing sensitive indicators, core measures, HCAPS, patient satisfaction and associate satisfaction.
Participated in development, implementation and evaluation of action plans for continuous performance improvement.
Functioned as charge nurse and assumed patient care in absence of nurses ending or arriving for shifts.
Participated in monitoring, maintaining and improving nursing sensitive indicators, core measures and other identified outcome measures.
Prioritized patient care assignments based on patient condition, responding to unanticipated interruptions while delegating care to achieve optimal, safe and effective outcomes.
Managed all facets of telemetry, including PA catheters and arterials, vasoactive drug administration and titration, thrombolytic therapy, dysrhythmia interpretation and chest tube management.
Collaborated with interdisciplinary healthcare professionals to create, implement and adapt individualized plans of care to restore patients' health and drive recovery goals.
Assessed patients, documented observations and reviewed patient charts to determine care needs.
Collaborated with doctors to plan post-treatment home care and prevent return hospitalization due to complications.
Treated patients with broad range of diagnoses ranging from sepsis, renal failure, diabetic ketoacidosis, pulmonary embolism, myocardial infarction, pneumonia, acute respiratory distress syndrome, congestive heart failure and chronic obstructive pulmonary disease.
Utilized computerized Resource and Patient Management System (RPMS) and Electronic Health Record (EHR) system.
Provided direct care in critical care units, including ICU/CCU.

Education and Training

Associate of Applied Science: NursingColumbia State Community College | | City, State | May 1995

Resume Overview

School Attended

Columbia State Community College

Job Titles Held:

RN/ Clinical Documentation Integrity Specialist
RN/Clinic Nurse Manager
RN Staff Nurse
RN/ICU Staff Nurse

Degrees

Associate of Applied Science : Nursing

RN/ Clinical Documentation Integrity Specialist Resume Example

Resume Score: 80%

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