Detail-oriented Clinical Documentation Specialist with expertise in ICD-10 coding and regulatory compliance. Proven track record in enhancing documentation practices and training staff to improve patient record quality.
Overview
1
1
Certification
24
24
years of professional experience
Work History
Clinical Documentation Specialist-Team Lead
BILH-Boston
Boston, Massachusetts
09.2015 - Current
Reviewed clinical documentation for accuracy and completeness, improving overall quality of patient records.
Collaborated with healthcare providers to enhance documentation practices.
Educated staff on regulatory compliance and best documentation standards.
Analyzed data trends to pinpoint areas for documentation improvement.
Assisted in training new staff on documentation processes and systems, facilitating smoother onboarding and integration.
Developed resources and guides for effective clinical documentation practices.
Provided education to healthcare professionals on proper utilization of ICD-10 codes and other relevant coding guidelines.
Developed and implemented policies and procedures related to clinical documentation improvement initiatives.
Reviewed medical records to ensure accuracy and completeness of clinical documentation.
Operating Room Registered Nurse
BIDMC-Milton
Milton, Massachusetts
10.2016 - 06.2017
Maintained a sterile environment in the operating room by adhering to aseptic techniques.
Managed surgical instruments, ensuring availability and cleanliness for each procedure.
Collaborated with surgeons, anesthesiologists, and surgical technologists to facilitate efficient surgical procedures.
Ensured appropriate positioning of patients on the operating the table prior to surgery.
Documented patients' medical records accurately throughout the perioperative process to ensure continuity of care.
Operating Room Registered Nurse
BILH-Boston
Boston, Massachusetts
09.2002 - 12.2015
Maintained a sterile environment in the operating room by adhering to aseptic techniques.
Trained new nurses on operating room protocols and safety procedures.
Collaborated with surgeons, anesthesiologists and other healthcare professionals to provide optimal care for patients.
Initiated emergency resuscitative measures when indicated in the event of complications or unexpected outcomes.
Advocated for patient needs and preferences throughout the surgical process to ensure patient-centered care.
Ensured appropriate positioning of patients on operating table prior to surgery.
Documented patient's medical record accurately throughout perioperative process to ensure continuity of care.
Education
Diploma in Nursing - Nursing
Brockton Hospital School of Nursing
Brockton, MA
05-1996
Bachelor of Science - Psychology
Bridgewater State University
Bridgewater, MA
05-1992
Skills
ICD-10 coding
Proficient in Epic and Solventum
Strong attention to detail
Accomplishments
Clinical Nurse IV advancement-2017
Joseph P. Kaufman Award for Perioperative Excellence-2012
Registered Nurse/Clinical Documentation Specialist at Baylor Scott & White HealthRegistered Nurse/Clinical Documentation Specialist at Baylor Scott & White Health