Clinical Documentation Integrity Specialist
Carla McCowan
Registered Nurse
Jacksonville,Fl
Summary
Registered nurse with over 20 years of experience in acute care, home health, and quality assurance. Expertise in chart review, clinical documentation improvement, and interdisciplinary care planning. Proficient in assessing functional capacity and utilizing electronic health records (EHR) to facilitate evidence-based decisions. Acknowledged for strong clinical judgment, regulatory knowledge, and ability to thrive in fast-paced remote and collaborative healthcare settings.
Overview
24
24
years of professional experience
1
1
Certification
Work History
Charge Nurse, Medical-Surgical Unit
UF Health
Jacksonville, FL
02.2020 - Current
- Supervise nursing teams and manage patient assignments, disputes, and complaints.
- Perform comprehensive patient care and cross-system coordination with other providers.
- Lead audits and documentation reviews to ensure regulatory compliance and quality outcomes.
Travel Nurse, Medical-Surgical Unit
University of Iowa Hospitals and Clinics
01.2024 - 06.2024
- Delivered total patient care including IV/PO/SQ/IM medication administration, order fulfillment, and assessments.
- Regularly served as charge nurse for a 20-bed med-surg unit.
- Conducted quality audits (pain, restraint, foley) and supported documentation compliance.
QA/QI Nurse Supervisor & Case Manager
Rehabilitation Home Health
Jacksonville, FL
08.2013 - 11.2019
- Oversaw documentation quality for a team of 11 clinicians; reviewed OASIS, ICD-10 coding, and plan-of-care accuracy.
- Educated staff on Medicare documentation standards and charting practices.
- Managed care transitions, discharge planning, and remote care coordination for diverse populations.
- Championed the integration of new technology into daily workflows by leading demonstrations, troubleshooting issues as needed, and offering support during the transition phase.
- Maintained compliance with regulatory standards through diligent monitoring and prompt resolution of identified issues.
- Trained, evaluated and coached clinical staff to improve performance.
Assistant Director of Nursing & Staff Development Coordinator
Jacksonville Nursing & Rehab Center
12.2007 - 01.2013
- Directed clinical staff of 120+ and maintained infection control and training programs.
- Developed compliance protocols and performed clinical documentation reviews.
ICU, ED, Radiology RN
Various Facilities via Travel & Per Diem Roles
, Florida
07.2002 - 01.2007
- Delivered critical care in emergency and intensive care units.
- Provided ACLS-level interventions and collaborated with multidisciplinary teams under pressure.
- Education & Credentials
- Collaborated with interdisciplinary teams for accurate diagnosis and treatment planning, optimizing patient care.
- Assisted physicians with various diagnostic imaging procedures, facilitating timely detection of medical conditions.
- Reduced patient anxiety through clear communication of procedure details, answering questions, and providing emotional support.
Education
Bachelor of Science in Nursing - Nursing
University of North Florida
Jacksonville, FL05.2002
Skills
Customer service and advocacy
Electronic health records management
Clinical documentation review
Medical record auditing
Care plan development
Microsoft Office Suite proficiency
Remote communication skills
Epic EMR expertise
Team leadership abilities
Nursing care coordination
Decision-making strategies
Key Qualifications
- Expert in chart audits, OASIS accuracy, and ICD-10 coding
- Developed, reviewed, and optimized comprehensive care plans
- Familiar with Medicare, CMS guidelines, and clinical documentation standards
- Experienced in staff education and regulatory compliance
- Strong cross-functional communication with case managers, providers, and patients
- Adept in remote work environments and clinical technology platforms
- Clinical Experience
Certification
Certified Medical-Surgical Registered Nurse
Interests
Timeline
Travel Nurse, Medical-Surgical Unit
University of Iowa Hospitals and Clinics
01.2024 - 06.2024
Certified Medical-Surgical Registered Nurse
05-2023
Charge Nurse, Medical-Surgical Unit
UF Health
02.2020 - Current
QA/QI Nurse Supervisor & Case Manager
Rehabilitation Home Health
08.2013 - 11.2019
Assistant Director of Nursing & Staff Development Coordinator
Jacksonville Nursing & Rehab Center
12.2007 - 01.2013
ICU, ED, Radiology RN
Various Facilities via Travel & Per Diem Roles
07.2002 - 01.2007
Bachelor of Science in Nursing - Nursing
University of North Florida