Heather Schmidt
Midland
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 through education while seeking opportunities for improvement.
Overview
17
17
years of professional experience
Work History
Regional Director CDI- Inpatient Rehab
PAM Health
Enola, PA
02.2025 - Current
- Conducts concurrent and retrospective audits of the medical record to ensure that the reason for admission is appropriate.
- Analyzes the medical record for opportunities to capture additional comorbidities to match resource consumption.
- Initiates compliant queries, as needed, to clarify findings, ambiguous, or conflicting documentation in the patient record when discovered.
- Collaborates with multidisciplinary teams to provide education and improve clinical documentation to accurately reflect the patient status.
- Provides supervisory oversight to the Patient Assessment Coordinator to ensure workflow and medical record accuracy.
Clinical Documentation Specialist
Midland Memorial Hospital
Midland, TX
08.2024 - 02.2025
- 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 education to Physicians while serving as a CDI subject matter expert to reduce inaccurate documentation and denial reduction
- 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
Midland, TX
01.2021 - 08.2024
- Care coordinator for patients discharging from acute care and/or rehab facilities to facilitate smooth transitions home
- Ensure complete and accurate orders are obtained for admission for PEG, IV infusions, PICC line care, and wound care management as needed
- 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
- Oversee 2 community educators while advising and assisting them with referrals and community events as needed
Clinical Supervisor
Texas Home Health, formerly Accolade Homecare
Odessa, TX
01.2018 - 01.2021
- Supervision of clinical staff on assigned teams
- Oversee safe and compliant patient care
- Lead case conferences
- Provide clinical guidance and education to nurses, aides, therapists on monthly and as needed basis
- Stay up to date with CMS guidelines and Oasis data collection
- Direct patient care after hours and weekends
- Meet time sensitive deadlines
- Providing training for all new employees
- Serve as alternate Director of Nurses and Alternate Administrator biweekly
Director of Nursing
Accolade Homecare
Midland, TX
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
Accolade Homecare
01.2011 - 01.2016
- Provide oversight of patient care on assigned teams
- Build patient plan of care
- Provide clinical guidance and education to nurses, aides, therapists on monthly and as needed basis
- Assist DON with weekly case conference and provide education to specific diagnosis, plan of care criteria, CMS guideline changes and Oasis date collection
- Stay up to date with CMS guidelines and Oasis data collection
- Participate in after hours and weekend administrator call biweekly
- Serve as alternate Director of Nurses and Alternate Administrator biweekly
Registered Nurse- IMCU
Medical Center Hospital
Odessa, TX
01.2009 - 01.2011
- Assess patients before and after cardiac procedures including heart cath and CABG
- Provide all aspects of patient care using nursing knowledge and skills
- Analyze lab results and patient conditions
- Contact physicians accordingly for patient needs or changes in patient status
- Coordinate with nurses, therapists, radiology, pharmacy, dietary and Physicians as needed for prompt and accurate care
- 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
- Focused on documentation compliance and accuracy
- Seeks opportunities for improvement
- Proficient in Microsoft office
- Exemplary in teamwork and collaboration
- Problem-solving skills
- Attention to detail
- Reliable and adaptable
- Self motivated
- Analytical skills
- Excellent communication
Timeline
Regional Director CDI- Inpatient Rehab
PAM Health
02.2025 - Current
Clinical Documentation Specialist
Midland Memorial Hospital
08.2024 - 02.2025
Clinical Care Coordinator
Midland Health at Home, formerly Calvert Home Health
01.2021 - 08.2024
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
Accolade Homecare
01.2011 - 01.2016
Registered Nurse- IMCU
Medical Center Hospital
01.2009 - 01.2011
Associate of Science - Nursing
Midland College