Experienced nursing professional bringing demonstrated clinical expertise, leadership skills and technical knowledge. Proficient in updating charts, monitoring medications and working with multidisciplinary teams to optimize patient care. Quality-driven and efficient with strong interpersonal abilities.
Overview
23
23
years of professional experience
Work History
Clinical Documentation Specialist
Health First
Melbourne, FL
06.2016 - 02.2024
Participated in regular meetings with physicians, nurses, case managers, coders, therapists. to discuss changes or improvements needed for clinical documentation processes.
Maintained current knowledge of ICD-10 coding requirements, CPT and HCPCS coding systems, DRG assignment criteria and CMS regulations.
Identified discrepancies in documentation with providers and resolved inconsistencies in a timely manner.
Maximized accuracy and completeness of medical records through in-depth audits and patient information reviews.
Provided education to healthcare professionals on proper utilization of ICD-10 codes and other relevant coding guidelines.
Acquired strong background in medical terms, illnesses and conditions and medical procedures.
Clinical Documentation Specialist
Wuesthoff Medical Center Rockledge
Rockledge, FL
07.2015 - 06.2016
Participated in regular meetings with physicians, nurses, case managers, coders, therapists. to discuss changes or improvements needed for clinical documentation processes.
Explained to entire healthcare team importance of providing in-depth, accurate medical records and documentation
Maintained current knowledge of ICD-10 coding requirements, CPT and HCPCS coding systems, DRG assignment criteria and CMS regulations.
Monitored compliance with regulatory standards for the Clinical Documentation Improvement program.
Maximized accuracy and completeness of medical records through in-depth audits and patient information reviews.
Identified discrepancies in documentation with providers and resolved inconsistencies in a timely manner.
Demonstrated knowledge of HIPAA Privacy and Security Regulations by appropriately handling patient information.
Provided education to healthcare professionals on proper utilization of ICD-10 codes and other relevant coding guidelines.
Acquired strong background in medical terms, illnesses and conditions and medical procedures.
Case manager
Wuesthoff Medical Center Rockledge
Rockledge
11.2013 - 07.2015
Responsible for managing the patient through the continuum of care including utilization review and discharge planning
Working with physicians and nurses, strived to provide the best care for the patient in the most cost effective way
Attended educational classes including Medicare Boot Camp, DRG training and a case management training through Compass training
Also performed case manager duties on the nursing floors, served as the observation nurse, emergency department case manager, and assisted in the pilot of the admission utilization nurse.
Cardiac nurse
Wuesthoff Medical Center Rockledge
Rockledge
02.2012 - 11.2013
After a year off work, returned to 2 Tower and resumed previous position as a cardiac nurse.
Clinical case coordinator
Wuesthoff Brevard Homecare
08.2010 - 03.2011
Responsible for managing the care of a team of 25-35 patients
Responsibilities included managing and scheduling home health aides, coordinating with physicians, coordinating medication management, and direct nursing care.
Registered Nurse
Wuesthoff Medical Center Rockledge
Rockledge, FL
11.2008 - 08.2010
Gained experience in multiple aspects of cardiac, cardiovascular, and pulmonary care
Also worked in the intensive care unit
Responsibilities and nursing skills include relief charge nurse, preoperative/postoperative management of surgical patients, pre/post procedure management of multiple types of cardiac interventions, assessment and medical management of cardiac and cardiovascular disorders, and various clinical skills.
Registered Nurse
Melbourne GI Center
Melbourne, FL
07.2007 - 11.2008
Responsible for pre and post procedure management of patient care, post procedure follow up care calls, obtaining and maintaining intravenous medications, mixing IV medications, and inventorying medications and supplies.
Registered Nurse
Holmes Regional Medical Center
Melbourne, FL
09.2000 - 07.2007
Worked on the trauma surgical/progressive care unit
Gained experience with trauma patients, including spinal cord injury patients and patients with traumatic wounds and complex fractures
Involved in the development of long term care plans for patients
Also worked with various types of surgical patients
Responsibilities and nursing skills include relief charge nurse, management of ventilators, tracheotomy care, multiple types of gastric tubes, colostomy care, urostomy care, external fixator care, continuous passive motion machine, wound management, management of surgical drains, and integrating patient care between multiple disciplines.