James Luna
Lubbock,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.
Overview
35
35
years of professional experience
Work History
Clinical Documentation Specialist/Clinical Appeal
Lubbock Heart Hospital
11.2021 - Current
- Facilitated interdisciplinary collaboration between physicians, nurses, case managers, coders, and other relevant stakeholders regarding the appropriate representation of patient severity levels within EHRs.
- Analyzed data from audits to identify areas for improvement in clinical documentation processes, implementing targeted interventions for positive change.
- Expedited accurate clinical documentation completion by promptly responding to queries from healthcare providers and support staff, offering timely guidance and support.
- Reduced risk exposure by promptly addressing any identified discrepancies or inconsistencies within patient records.
- Communicated with physicians, nurses and other caregivers to explain importance of accurate and clear documentation.
- Effectively managed multiple priorities while maintaining strict adherence to established deadlines, ensuring the consistent delivery of exceptional clinical documentation services.
- Collaborated with multidisciplinary teams to develop best practices in clinical documentation, streamlining processes and reducing errors.
- Maintained strong knowledge of medical terminology, diseases and conditions and procedures.
- Contributed to revenue optimization by identifying opportunities for appropriate clinical documentation improvement.
- Carefully reviewed patient files for clarity on diseases, diagnoses and procedures to determine quality of care.
- Served as a resource for healthcare professionals seeking guidance on various aspects of clinical documentation, fostering effective communication among team members.
- Questioned physicians regarding missing or unclear health record documentation and requested further information for clarification purposes.
- Improved clinical documentation quality by conducting thorough reviews and providing feedback to healthcare providers.
- Processed records quickly to avoid delays and keep workflows running smoothly.
Clinical Documentation specialist
Eastern New Mexico Medical Center
04.2018 - 10.2021
- Facilitated interdisciplinary collaboration between physicians, nurses, case managers, coders, and other relevant stakeholders regarding the appropriate representation of patient severity levels within EHRs.
- Analyzed data from audits to identify areas for improvement in clinical documentation processes, implementing targeted interventions for positive change.
- Expedited accurate clinical documentation completion by promptly responding to queries from healthcare providers and support staff, offering timely guidance and support.
- Reduced risk exposure by promptly addressing any identified discrepancies or inconsistencies within patient records.
- Effectively managed multiple priorities while maintaining strict adherence to established deadlines, ensuring the consistent delivery of exceptional clinical documentation services.
- Collaborated with multidisciplinary teams to develop best practices in clinical documentation, streamlining processes and reducing errors.
- Maintained strong knowledge of medical terminology, diseases and conditions and procedures.
- Served as a resource for healthcare professionals seeking guidance on various aspects of clinical documentation, fostering effective communication among team members.
- Participated in continuous education programs, staying up-to-date on industry trends and best practices in clinical documentation management.
- Educated healthcare staff on the importance of proper clinical documentation, fostering a culture of accuracy and accountability.
- Questioned physicians regarding missing or unclear health record documentation and requested further information for clarification purposes.
Med/Surg Nursing Director
ENMMC
05.2013 - 04.2018
- Developed high-performing teams by providing mentorship, guidance, and opportunities for professional growth.
- Enhanced team collaboration through regular communication, goal setting, and performance evaluations.
- Assumed management responsibilities of the department with 6 permanent staff RN's out an FTE need of 24
- Upon completion of assignment only 1 RN FTE remained open
- Collaborated with a multidisciplinary team daily, for improvement in discharge processes and improved overall patient care
- Led and motivated 45+ employees through supervision, training and coaching on duties and daily operational activities
- Initiated training and education programs for supporting healthcare staff
- Resolved conflict promptly among staff physicians, nursing and other healthcare employees to keep workflow on task
- Managed operations in accordance with budget requirements
- Developed high-performing teams by providing mentorship, guidance, and opportunities for professional growth.
Emergency Department Nursing Director
ENMMC
08.2009 - 05.2013
- Assumed management responsibilities of a 16 bed ER as interim director, and successfully prepared the team in 6 months for a Joint Commission survey that found no finding in the Emergency department, I then accepted the full time position as Director
- Developed high-performing teams by providing mentorship, guidance, and opportunities for professional growth.
- Oversaw the building and completion of a new 23 bed emergency department working with contractors, architects and our plant operations director
- Implemented and trained all staff on Pro-Med electronic health record during the transition from old department into the new department to go fully electronic upon opening
Charge Nurse Assistant Director Surgical unit
ENMMC
03.2005 - 07.2009
- Upon completion of NCLEX exam moved from the Emergency department into a staff RN position in the Critical Care Unit
- While in the Critical care unit I worked as a Charge nurse
- On January 07 I began as the Asst
- Director of the Surgical unit
- During this time I completed training as a wound and ostomy nurse focussing on wound care specialty, implementing wound care practices that continue to this day
ER Technician/ Orthopedic technician/ Limited license radiology Technician (Chest and extremities) Office manager/ Board certified ortho scrub tech/ Endoscopy Tech
ENMMC
09.1993 - 03.2005
- Er Tech- IV certified medic assisted in all trauma care and nursing assist in care of all types of presentations to the Emergency Department
- Managed an orthopedic clinic overseeing the schedule of patients assisting Surgeon with simple clinic procedures including FX reductions application of casts, splints, and removal of sutures staples and many other duties as needed
- Limited License radiology technician - useful during Orthopedic time to xray an improve turnaround times for orthopedic clinic
- Office Manager for New Orthopedic Surgeon on staff with ENMMC, Provided all duties as Ortho clinic including assisting in surgery and managing 3 staff members in the office
- 2002 - returned to Nursing school and worked as an endoscopy Technician full time while attending nursing school
Medical Service Specialist
United States Air Force
09.1989 - 09.1993
- Desert Storm Veteran- Medical Specialist
- Emergency Room - Medic
- 18 bed ER- 100+ pt /day 2 physicians 1 RN 7 Medics
- Operated 3 ambulances for emergency responses on base and in civilian area during Crisis situations (Hurricane Preparation)
- CCU medical specialist Keesler AFB 500+ bed facility 32 bed Critical care unit
Education
Associates degree - Nursing
Eastern New Mexico University
Roswell, NM12.2004
Skills
- ICD-10 DRG Coding Expertise
- Documentation query compliance
- Strategic planning
- Data analysis
- Patient Data Abstract
- Physician Communication
- Healthcare Terminology Expertise
- Strong Verbal and Nonverbal Communication
- Charting & Clinical Documentation
- Analytical Problem Solving
Personal Information
Title: RN Clinical Documentation Specialist
Timeline
Clinical Documentation Specialist/Clinical Appeal
Lubbock Heart Hospital
11.2021 - Current
Clinical Documentation specialist
Eastern New Mexico Medical Center
04.2018 - 10.2021
Med/Surg Nursing Director
ENMMC
05.2013 - 04.2018
Emergency Department Nursing Director
ENMMC
08.2009 - 05.2013
Charge Nurse Assistant Director Surgical unit
ENMMC
03.2005 - 07.2009
ER Technician/ Orthopedic technician/ Limited license radiology Technician (Chest and extremities) Office manager/ Board certified ortho scrub tech/ Endoscopy Tech
ENMMC
09.1993 - 03.2005
Medical Service Specialist
United States Air Force
09.1989 - 09.1993
Associates degree - Nursing
Eastern New Mexico University
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