Lynette Mueses
Spring,TX
Summary
Results-driven Clinical Documentation Specialist with expertise in medical terminology, coding, and compliance. Enhanced clinical documentation processes to ensure accuracy, improving patient care quality and operational efficiency. Skilled in critical thinking and process improvement, adaptable to fast-paced environments, and excels under pressure.
Overview
1
1
Certification
2027
2027
years of professional experience
Work History
Clinical Documentation Specialist
Houston Methodist
Houston, Texas
12.2025 - Current
- - Reviewed charts thoroughly and delivered actionable feedback to enhance clinical documentation practices among health care providers.
- - Supported documentation improvement efforts to strengthen coding accuracy and billing compliance.
- - Found process gaps and helped maintain alignment with coding and billing regulations.
- - Facilitated discussions with physicians to ensure accurate clarification of diagnoses, procedures, and comorbidities.
- Queried physicians to clarify diagnoses, procedures, and comorbidities.
- Tracked documentation patterns in the Epic electronic health record to identify areas for improvement in clinical accuracy and compliance.
- Collaborated with Houston Methodist care teams on clinical record accuracy.
- Educated providers on clear clinical documentation practices to support accurate coding and improve patient care.
- Identified discrepancies in documentation with providers and resolved inconsistencies in a timely manner.
- Maintained current knowledge of ICD-10 coding requirements, CPT and HCPCS coding systems, DRG assignment criteria and CMS regulations.
- Analyzed data from multiple sources including laboratory, radiology and pathology reports.
- Reviewed medical records to ensure accuracy and completeness of clinical documentation.
- Worked with speed, efficiency and accuracy to process documentation and complete projects.
Clinical Documentation Specialist
Memorial Hermann Health System
Houston, TX
06.2021 - 12.2025
- Reviewed inpatient charts for documentation completeness and medical necessity.
- Reviewed medical records for accuracy and completeness, supporting high-quality clinical documentation standards.
- Queried physicians to clarify diagnoses, procedures, and comorbidities.
- Collaborated with providers to identify and resolve documentation discrepancies, ensuring timely corrections.
- Analyzed documentation patterns in the Epic electronic health record to enhance accuracy and compliance.
- Educated providers on clear clinical documentation practices.
- Applied ICD-10 and DRG guidelines to support accurate coding.
COVID
Memorial Hermann Health System
Houston, TX
04.2020 - 06.2021
- Coordinated day-to-day operations of screening station at Woodlands, ensuring efficient service delivery and adherence to health protocols.
- Resolved customer issues with knowledgeable and friendly service, enhancing overall satisfaction and fostering positive relations.
- Completed day-to-day duties accurately and efficiently.
- Contributed innovative ideas and solutions to enhance team performance and outcomes.
- Worked successfully with a diverse group of coworkers to accomplish goals and address issues related to our products and services.
Wound Center Nurse
Memorial Hermann Health System
Houston, TX
11.2019 - 06.2021
- Managed treatment for complex wounds in specialized care including diabetic ulcers, vascular wounds, and trauma-related wounds.
- Conducted thorough wound assessments to develop effective treatment plans in hospital wound care unit, documenting findings in EMR.
- Performed sterile dressing changes following physician orders and facility protocols.
- Monitored wounds for signs of infection, drainage, and changes in skin condition to ensure timely interventions.
- Collaborated with physicians, therapists, and case managers on care plans.
- Educated patients and families on proper wound care techniques, hygiene practices, and dressing changes to promote healing.
- Documented patient medical histories for accurate assessments and reviewed charts before wound assessments.
- Utilized specialized equipment such as negative pressure therapy systems, pulsed lavage devices, for optimal wound healing outcomes.
CLINICAL NURSE MANAGER II
Memorial Hermann Health System
Houston, TX
12.2017 - 11.2019
- Managed Memorial Hermann clinical nursing staff schedules and daily unit coverage.
- Coordinated patient care plans with physicians, therapists, and case managers.
- Led staff coaching on bedside care standards and patient safety practices.
- Facilitated interdisciplinary collaboration among physicians, nurses, therapists, pharmacists.
- Supported quality improvement efforts across Memorial Hermann nursing operations.
- Monitored Memorial Hermann nursing practice for policy and regulatory compliance.
- Participated actively in recruitment and selection processes for new hires.
- Established effective communication channels between clinical staff members and other departments.
- Established and maintained positive relationships with residents, physicians, hospital staff, patients and families.
- Performed assessments of the health needs of individual patients as well as populations within the facility.
- Ensured compliance with regulatory requirements by conducting audits on a regular basis.
- Maintained appropriate documentation of patients' medical records according to established standards.
CLINICAL COORDINATOR ICU & MEDICAL DIVISION / INTERIM PATIENT CARE DIRECTOR
New York Presbyterian Hospital/Columbia University Medical Center
New York, NY
01.2014 - 01.2017
- Supervised nursing staff and coordinated patient care workflows to ensure effective daily operations.
- Monitored patient acuity and assigned nurses to appropriate bedside care.
- Provided leadership and guidance to co-workers, ensured accurate training for staff, and addressed issues to promote productivity in a supportive environment. Managed performance reviews, recruited high-quality talent, and determined per diem for agency nurses.
- Collaborated with physicians, respiratory therapists, and pharmacists on care plans.
- Managed staff performance discussions and supported professional development.
- Participated in interdisciplinary team meetings regarding patient care plans.
- Monitored patient outcomes to identify trends needing additional resources or interventions, facilitating timely responses to patient needs.
- Assessed nursing staff performance through regular observation and structured feedback sessions. of nursing staff on a regular basis through observation and feedback sessions.
- Collaborated with other departments within the hospital to ensure efficient workflow between units.
- Served as liaison between physicians, administrators, and other healthcare personnel involved in providing care in the nursing unit.
- Developed and implemented policies, procedures, and protocols for staff.
- Enforced critical care standards, infection control, and patient safety protocols.
CLINICAL COORDINATOR NEUROSCIENCE DEPARTMENT
ACCESS CENTER
01.2013 - 01.2014
- Coordinated daily activities of the neuroscience department, providing leadership and streamlining administrative processes for staff.
- Verified patient identity before each transfer and destination change.
- Updated clinical staff and reception teams on patient status and transfer delays to improve communication and patient flow.
- Worked with nursing staff to ensure precise documentation of patient transfers in medical records, enhancing accuracy and compliance.
- Safely transported patients between Hospitals and within hospital departments.
- Followed hospital policies, privacy rules, and emergency response procedures.
CLINICAL NURSE I (MICU)
ACCESS CENTER
01.2011 - 01.2013
- Offered patient care in a clinical setting including assessing patients' condition, administering medications, setting up IVs, updating patient records, providing emotional support, and educating patients on the best course of action to manage their illness or injury.
- Monitored ICU patients' vital signs and assessed overall condition to ensure timely interventions in a critical care environment.
- Responded quickly to emergencies and urgent patient care needs.
- Collaborated with physicians, respiratory therapists, and care team members to coordinate comprehensive patient care plans.
- Documented assessments, treatments, and patient responses in medical records.
- Maintained accurate records of vital signs, fluid intake and output levels, daily weights and laboratory results.
- Functioned as charge nurse and assumed patient care in the absence of nurses ending or arriving for shifts.
- Developed and maintained a professional relationship with members of the health care team, the patient, and the patient's family.
- Performed bedside procedures, including wound dressing changes, nasogastric tube placement, and urinary catheter insertion, ensuring patient comfort and safety.
Staff Travel Nurse
American Mobile Intervention Radiology/Princeton Medical Center
San Diego, CA
- Delivered bedside care across travel assignments in acute and specialty units
- Administered medications and monitored responses following facility protocols
- Assessed patient conditions and updated care plans during shift handoffs
- Collaborated with healthcare team to develop and implement patient care plans.
- Educated patients and families on recovery steps and discharge instructions
- Demonstrated excellent communication skills while interacting with patients, family members, physicians and other health professionals.
- Adapted quickly to new hospital policies, workflows, and unit expectations
Staff Nurse, Cardiac Care Unit (CCU) Staff Nurse, and Medical/Surgical Unit Staff Nurse
Hackensack University Medical Center
Hackensack, NJ
- Executed rapid interventions during cardiac emergencies to stabilize patients using CCU protocols and nursing judgment.
- Administered medications and monitored patient responses in a cardiac care setting.
- Assessed cardiac rhythms and escalated changes to the critical care team.
- Ensured proper functioning of PA catheters and arterial lines, managing vasoactive drug administration, thrombolytic therapy, dysrhythmia interpretation, and chest tube management.
- Collaborated with interdisciplinary healthcare professionals to develop and adapt individualized care plans, enhancing patient outcomes.
- Collaborated with physicians, respiratory therapists, and nursing staff during bedside care.
- Performed CPR and other emergency medical procedures.
- Assessed patients, documented observations and reviewed patient charts to determine care needs.
- Assisted physicians during examinations and procedures by operating and monitoring medical equipment.
- Managed central lines, drains, and cardiac monitoring equipment.
- Applied evidence-based practices to wound care, preventing infections and promoting healing.
- Maintained infection control and safety standards in an intensive care environment.
- Delivered high-quality care by following clinical standards and implementing process improvements.
Education
Master of Science - Nursing
SETON HALL UNIVERSITY
South Orange, NJ01-2017
Bachelor of Science - Nursing
SETON HALL UNIVERSITY
South Orange, NJ01-2000
Skills
- EPIC proficiency
- Medical terminology
- Documentation improvement
- Documentation compliance
- Health records management
- Regulatory updates
- Healthcare compliance
- Problem-solving capacity
- Multitasking efficiency
- Attention to detail
Certification
- State of Texas - Registered Nurse License # 918323 - Active
State of New York- Registered Nurse License # 22639645- Active
State of New Jersey- Registered Nurse License # 26NO12237300- Active
State of California - Registered Nurse License # 605946- not Active
American Heart Association- Advance Cardiac Life Support expires 1/2027
American Heart Association- Basic Life Support expires 2/2027
Languages
Spanish, English
Areas of Expertise include:
- Mentorship & Leadership
- Patient Relations
- Quality Assurance
- Critical Care
- Clinical Review of Record
- Neuro ICU/Neuro
- Adult Gerontological/Neurology
- Joint Commission
- HIPAA Compliance
- Acute Care
- Phlebotomist
- Medical Records
Timeline
Clinical Documentation Specialist
Houston Methodist
12.2025 - Current
Clinical Documentation Specialist
Memorial Hermann Health System
06.2021 - 12.2025
COVID
Memorial Hermann Health System
04.2020 - 06.2021
Wound Center Nurse
Memorial Hermann Health System
11.2019 - 06.2021
CLINICAL NURSE MANAGER II
Memorial Hermann Health System
12.2017 - 11.2019
CLINICAL COORDINATOR ICU & MEDICAL DIVISION / INTERIM PATIENT CARE DIRECTOR
New York Presbyterian Hospital/Columbia University Medical Center
01.2014 - 01.2017
CLINICAL COORDINATOR NEUROSCIENCE DEPARTMENT
ACCESS CENTER
01.2013 - 01.2014
CLINICAL NURSE I (MICU)
ACCESS CENTER
01.2011 - 01.2013
Staff Travel Nurse
American Mobile Intervention Radiology/Princeton Medical Center
Staff Nurse, Cardiac Care Unit (CCU) Staff Nurse, and Medical/Surgical Unit Staff Nurse
Hackensack University Medical Center
Master of Science - Nursing
SETON HALL UNIVERSITY
Bachelor of Science - Nursing
SETON HALL UNIVERSITY