Melissa Wouters
Prattville
Summary
Detail-oriented clinical documentation improvement (CDI) specialist with ten years of experience optimizing health care documentation practices to enhance patient care, compliance and revenue integrity. Proficient in conducting comprehensive chart reviews, denial audit reviews offering feedback to CDI staff/management and healthcare providers , implementing effective documentation improvement strategies. Adept at identifying areas for process enhancement and ensuring compliance query process.
Overview
38
38
years of professional experience
1
1
Certification
Work History
Clinical Documentation Improvement Specialist
Baptist Medical Center South
10.2013 - Current
- Achieve reduction in documentation discrepancies and coding inaccuracies through comprehensive chart reviews, identifying documentation deficiencies, coding inaccuracies and compliance issues.
- Collaborate with health care providers to offer education and feedback on documentation improvement.
- Concurrent review for discrepancies in health records query physician to provide further documentation to clarify
- Concurrent review of charts to establish DRG including principle diagnosis, secondary diagnosis and procedures , risk of mortality and severity of illness
Quality Management Analyst
Baptist Medical Center South
09.2008 - 10.2013
- Review hospital medical records and abstract the appropriate data elements associated with measures
- Entered abstractions into specified data collection application, including maintaining and updating data
- Knowledge of core measure requirements, abstraction guidelines and standards , set by CMS and TJC
RN, Emergency Department, Intensive Care
Baptist Medical Center Prattville And East
09.1986 - 12.2008
- Administered medications accurately and safely, reducing medication errors and adverse reactions.
- Enhanced patient satisfaction through effective communication, empathy, and timely response to their needs.
- Collaborated with interdisciplinary teams for comprehensive patient care plans, resulting in better health outcomes.
- Administered medications via oral, IV, and intramuscular injections and monitored responses.
- Collaborated with physicians to quickly assess patients and deliver appropriate treatment while managing rapidly changing conditions.
- Educated patients, families and caregivers on diagnosis and prognosis, treatment options, disease process, and management and lifestyle options.
- Assessed patient conditions promptly upon admission to determine appropriate interventions and prioritize care needs.
- Trained new nurses in proper techniques, care standards, operational procedures, and safety protocols.
- Provided direct patient care, stabilized patients, and determined next course of action.
- Participated in professional development opportunities regularly to stay current on best practices in the field of nursing.
- Managed complex cases of critically ill patients, ensuring optimal treatment plans were executed effectively.
Education
Bachelor of Science - Nursing
Troy State University
Montgomery, Al05.1983
Skills
- Analytical and critical thinking, understanding of clinical conditions acute and chronic
- Clinical documentation review
- Cerner, 3M 360, and Iodine efficient
- ICD-10-CM coding
- Medical terminology
- Electronic Health Records (EHR)
- Compliance and auditing
- Interdisciplinary communication
- Data analysis
- Time management
- Problem-solving
Certification
- Certified Clinical Documentation Specialist (CCDS) - (2015)
Timeline
Clinical Documentation Improvement Specialist
Baptist Medical Center South
10.2013 - Current
Quality Management Analyst
Baptist Medical Center South
09.2008 - 10.2013
RN, Emergency Department, Intensive Care
Baptist Medical Center Prattville And East
09.1986 - 12.2008
Bachelor of Science - Nursing
Troy State University
- Certified Clinical Documentation Specialist (CCDS) - (2015)
Similar Profiles
KERRI HARRELLKERRI HARRELL
Travel Registered Nurse-Emergency Department at Agency-RTG Medical-Baptist Medical Center SouthTravel Registered Nurse-Emergency Department at Agency-RTG Medical-Baptist Medical Center South
Faraqed MancillFaraqed Mancill
Travel ICU RN at Baptist Medical Center SouthTravel ICU RN at Baptist Medical Center South
Cherlynthia FlynnCherlynthia Flynn
Radiologic Technologist at Baptist Medical Center SouthRadiologic Technologist at Baptist Medical Center South