Compassionate healthcare professional with 18 years of experience in the emergency department of a level 1 trauma center. Demonstrated expertise in clinical excellence, leadership, and didactic skills. Comfortable in fast-paced emergency situations to ensure optimal patient outcomes. Experienced Clinical Documentation Specialist with background in healthcare settings. Demonstrated mastery of medical terminology, coding fundamentals, and compliance requirements. Previous roles involved enhancing clinical documentation processes for accuracy, leading to improved quality of patient care and streamlined operations.
Overview
17
17
years of professional experience
1
1
Certification
Work History
Clinical Documentation Specialist
Harbor UCLA Medical Center, LADHS
Torrance, CA
06.2017 - 04.2024
Monitored compliance with regulatory standards for the Clinical Documentation Improvement program.
Developed and implemented policies and procedures related to clinical documentation improvement initiatives.
Assisted physicians in development of comprehensive patient care plans through accurate coding and effective communication of results.
Collaborated with interdisciplinary teams to identify opportunities for improvement in clinical documentation processes.
Generated monthly reports that reflect performance metrics related to CDI activities.
Participated in regular meetings with physicians, nurses, case managers, coders, therapists. to discuss changes or improvements needed for clinical documentation processes.
Performed periodic audits of medical records to verify accuracy of coded diagnoses and procedures.
Developed strategies designed to improve quality outcomes associated with specific diagnosis groups.
Created educational materials related to best practices for accurate clinical documentation across all settings.
Actively participated in special projects related to improving overall quality scores within the organization.
Registered Nurse, Emergency Department
Harbor UCLA Medical Center, LADHS
Torrance, CA
12.2006 - 06.2017
Analyze data and assessments to develop an individualized plan of care for patients' physical, psychosocial, and educational needs, and rapidly identify changes in the patient's condition.
Facilitated discharge planning process to ensure continuity of care after leaving the facility.
Participated in quality improvement initiatives within the Emergency Department setting.
Coordinated care with physicians and other clinical staff to prepare for treatment, carry out interventions and enhance continuum of care.
Trained other nurses on patient care and daily tasks, supporting growth and professional development.
Provided emotional support and guidance to patients and families during stressful situations.
Participated in quality improvement initiatives to enhance patient care and department efficiency.
Managed patient triage, prioritizing care based on severity of condition and available resources.
Assisted in surgical procedures and provided post-operative care, ensuring optimal patient outcomes.
Facilitated seamless transfer of patients to other units or facilities, ensuring continuity of care.
Educated patients and families on disease management, prevention, and healthy lifestyle choices.
Education
Associate of Science - Nursing
Los Angeles Harbor College
Wilmington, CA
06-2006
Skills
Exemplary communication skills
Report creation
Process Improvements
Healthcare staff interaction
Clinical documentation oversight
Proficient in EHR Systems
Accomplishments
Daisy Award Nominee 2015
Certification
Board of Registered Nursing RN License #882948
Advanced Trauma Care for Nurses ATCN #ATCN104604
Mobile Intensive Care Nurse #N3908
ACLS
BLS
References
References available upon request.
Timeline
Clinical Documentation Specialist
Harbor UCLA Medical Center, LADHS
06.2017 - 04.2024
Registered Nurse, Emergency Department
Harbor UCLA Medical Center, LADHS
12.2006 - 06.2017
Board of Registered Nursing RN License #882948
Advanced Trauma Care for Nurses ATCN #ATCN104604
Mobile Intensive Care Nurse #N3908
ACLS
BLS
Associate of Science - Nursing
Los Angeles Harbor College
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