OBJECTIVE: . Dedicated Clinical Documentation Specialist professional with history of meeting company goals utilizing consistent and organized practices. Skilled in working under pressure and adapting to new situations and challenges to best enhance the organization.
Work History
Clinical Documentation Specialist RN
Phoenix Children's Hospital
Phoenix, AZ
12.2018 - Current
Maintained strong knowledge of medical terminology, diseases and conditions and procedures.
Questioned physicians regarding missing or unclear health record documentation and requested further information for clarification purposes.
Communicated with physicians, nurses and other caregivers to explain importance of accurate and clear documentation.
Carefully reviewed patient files for clarity on diseases, diagnoses and procedures to determine quality of care.
Clinical Documentation Specialist RN
Banner Health Thunderbird Hospital
Glendale, AZ
01.2017 - 12.2018
Maintained strong knowledge of medical terminology, diseases and conditions and procedures.
Questioned physicians regarding missing or unclear health record documentation and requested further information for clarification purposes.
Communicated with physicians, nurses and other caregivers to explain importance of accurate and clear documentation.
Clinical Documentation Specialist RN
Honor Health Deer Valley Hospital
Phoenix, AZ
12.2014 - 01.2017
Maintained strong knowledge of medical terminology, diseases and conditions and procedures.
Questioned physicians regarding missing or unclear health record documentation and requested further information for clarification purposes.
Communicated with physicians, nurses and other caregivers to explain importance of accurate and clear documentation.
Case Manager/RN
Christian Care Home Health
Phoenix, Arizona
06.2013 - 08.2014
Develop, implement, and evaluate individualized patient care plans.
Advocate patient welfare, and serve as a liaison between elderly patients, families, and healthcare providers.
Worked with Medicare and it's guidelines to provide skilled care for the elderly.
Liaised between patients and physicians to ensure patient comprehension of treatment plans.
Participated in unit-based Quality Assurance Program.
Staff Nurse Emergency Department/Staff Nurse Perioperative Services Department
John C. Lincoln Health network
Phoenix, Arizona
01.1999 - 05.2013
Assessed need for, ordered, obtained and interpreted appropriate lab tests.
Self-directed with astute judgment skills. High level of personal accountability.
Liaised between patients and physicians to ensure patient comprehension of treatment plans.
Instructed patients and family members on proper discharge care.
Closely monitored acute conditions.
Demonstrated ability to lead and motivate outstanding healthcare teams.
Ensured HIPAA compliance.
Diagnosed and treated patients with chronic and acute health problems such as MI, arrhythmias, asthma, COPD and pneumonia.
Participated in unit-based Quality Assurance Program.
Developed and implemented nursing care plans.
Scheduled patient admissions and discharges.
Managed care for post-operative patients through discharge.
Performed lab tests and communicated results.
Instructed patients and family members on proper discharge care.
Closely monitored acute conditions.
Documented patient information obtained from interviews.
Staff Nurse Emergency Department
Banner Thunderbird Hospital
Glendale, Arizona
01.1998 - 01.2004
Scheduled patient admissions and discharges.
Trained new staff on quality control procedures.
Ensured efficacy of treatments through monitoring of treatment regimens.
Delegated staff nurse duties.
Documented patient information obtained from interviews.
Developed patient care plans, including assessments, evaluations and nursing diagnoses.
Developed and implemented nursing care plans.
Diagnosed and treated patients with chronic and acute health problems such as MI, arrhythmias, asthma, COPD and pneumonia.
Ensured proper care for victims of domestic violence who presented to urgent care clinic.
Ensured HIPAA compliance.
Contributed substantially to successful department JCAHO accreditation.
ERT/RN
Maryvale Hospital/West Valley Hospital
Phoenix, Arizona
05.1995 - 05.1998
Assessed need for, ordered, obtained and interpreted appropriate lab tests.
Pharmacological and non-pharmacological management and treatment of various disorders and diseases.
Self-directed with astute judgment skills. High level of personal accountability.
Effective counseling in health maintenance and disease management.
Liaised between patients and physicians to ensure patient comprehension of treatment plans.
Instructed patients and family members on proper discharge care.
Closely monitored acute conditions.
Ensured HIPAA compliance.
Diagnosed and treated patients with chronic and acute health problems such as MI, arrhythmias, asthma, COPD and pneumonia.
Education
Bachelor of Science - Nursing
Grand Canyon University
Phoenix, AZ
2007
Associate Degree of Applied Science - Nursing
Glendale Community College
Glendale, AZ
1997
Skills
Strong clinical judgment
Fast learner
Team player
Adept at prioritizing/managing deadlines
Attention to Detail
Critical Thinking
Decision-Making
Self-Motivated
Accomplishments
I have been a RN for 25 years, 7 of those years as a Clinical Documentation Specialist. I am currently working on my CCDS certification.
Timeline
Clinical Documentation Specialist RN
Phoenix Children's Hospital
12.2018 - Current
Clinical Documentation Specialist RN
Banner Health Thunderbird Hospital
01.2017 - 12.2018
Clinical Documentation Specialist RN
Honor Health Deer Valley Hospital
12.2014 - 01.2017
Case Manager/RN
Christian Care Home Health
06.2013 - 08.2014
Staff Nurse Emergency Department/Staff Nurse Perioperative Services Department