Heather Schmidt
Midland,TX
Summary
Clinical documentation professional with proven track record in maintaining accurate medical records and supporting healthcare teams. Committed to enhancing patient care through precise documentation and collaboration. Valued for adaptability and reliability, ensuring compliance and quality in all tasks, knowledgeable in evaluating medical records to determine accuracy and overall care quality.
Overview
16
16
years of professional experience
Work History
Clinical Documentation Specialist
Midland Memorial Hospital
08.2024 - Current
- Perform concurrent, retrospective and reconciliation reviews to ensure the DRG accurately reflects the reason for admission and comorbidity conditions
- Initiates compliant queries both verbally and written to capture POA status, acuity, specificity and ambiguous or conflicting documentation as appropriate
- Assesses for opportunities within the medical record for accurate and complete documentation
- Responsible for providing up to date CDI information to Physicians and staff while serving as a CDI subject matter expert
- Collaborates with Physicians, Case managers, Utilization review and coding staff in via phone, email, staff meetings and one on one as needed
- Analyzes the medical record to assess proper capture of SOI/ROM to ensure resource consumption is accurately captured to the highest acuity and specificity
Clinical Care Coordinator
Midland Health at Home, formerly Calvert Home Health
01.2021 - Current
- Coordinate care for patients being discharged from hospital and rehab
- Ensure complete and accurate orders are obtained for admission
- Use nursing knowledge to review clinical information for ability to provide safe and appropriate care to patients
- Manage communication between the hospital staff, patients and Clinical staff
- Build relationships with members of the community
- Oversee2 community educators while advising and assisting them with referrals and events as needed
Clinical Supervisor
Texas Home Health, formerly Accolade Homecare
01.2018 - 01.2021
- Supervision of clinical staff on assigned teams
- Oversee patient care
- Lead case conferences
- Provide clinical guidance
- Direct patient care after hours and weekends
- Meeting time sensitive deadlines
- Providing training for all new employees
Director of Nursing
Accolade Homecare
01.2016 - 01.2018
- Direct all aspects of patient care and staffing using excellent communication and nursing knowledge
- Ensure plan of care is followed
- Manage patient and family complaints
- Available for administrative support for staff
- Assist in quality assurance and performance improvement
Quality Assurance Performance Improvement
01.2011 - 01.2016
- Provide oversight of patient care on assigned teams
- Build patient plan of care
- Provide clinical guidance and support
- Assist DON with case conference
- Participate in after hours and weekend administrator call
Registered Nurse- IMCU
Medical Center Hospital
01.2009 - 01.2011
- Provide all aspects of patient care using nursing knowledge and skills
- Analyze lab results
- Contact physicians accordingly for patient needs
- Coordinate with Therapists, Radiology, Pharmacy, Dietary and Physicians
- Provide discharge education
- Prepare patients for surgical procedures
- Insert and administer IV medications through Peripheral and PICC lines
- Attend continuing education seminars
Education
Associate of Science - Nursing
Midland College
Midland, TX05-2009
Skills
- Documentation compliance
- Process improvements
- Proficient in Microsoft office
- Teamwork and collaboration
- Problem-solving skills
- Attention to detail
- Reliability
- Self motivation
- Adaptability
- Analytical skills
- Excellent communication
Timeline
Clinical Documentation Specialist
Midland Memorial Hospital
08.2024 - Current
Clinical Care Coordinator
Midland Health at Home, formerly Calvert Home Health
01.2021 - Current
Clinical Supervisor
Texas Home Health, formerly Accolade Homecare
01.2018 - 01.2021
Director of Nursing
Accolade Homecare
01.2016 - 01.2018
Quality Assurance Performance Improvement
01.2011 - 01.2016
Registered Nurse- IMCU
Medical Center Hospital
01.2009 - 01.2011
Associate of Science - Nursing
Midland College
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