Dedicated Registered Nurse brings 24 year background in Nursing and over 13 years of experience in Home Healthcare. Polite and courteous professional with in-depth knowledge of OASIS documentation, ICD-10 coding, physical assessments, home safety evaluations, medication review, disease process teaching, wound care, and holistic patient care. Committed to collaborating with physicians and families to provide quality patient care.
•Perform comprehensive clinical record reviews of OASIS start of care, resumptions of care, re-certifications, follow up and change in focus for complete and accurate clinical documentation, within designated time frames, to ensure the OASIS and /or assessment accurately reflects the patients current health status.
•Accurately codes diagnoses and procedures on all OASIS using ICD-9(10) coding.
•Review documentation for necessity of services, congruency, accuracy, appropriateness, quality of care and compliance with physician orders and the plan of care to ensure quality care and reimbursement.
•Educate field staff on OASIS requirements, clinical documentation, clinician educational training and support, and State and Federal regulatory requirements.
•Maintain integrity and compliance in all chart reviews, documentation and queries at all times.
•Assure home care compliance with OASIS requirements and remains current with regulatory and organization requirements to ensure accurate and thorough quality assurance reviews.
• Utilize EMR systems: Wellsky and Axess
• Provide planning, directing and evaluating operations and delivery of overall clinical services.
• Provide leadership and guidance to assist clinicians providing direct patient care in meeting agency objectives, quality and compliance requirements on a local, state and federal level in accordance with Home Health rules and regulations.
• Perform health assessments of individuals by evaluating their physical, mental and environmental health status; provided nursing intervention based on assessment of need
• Complete Medicare OASIS assessments and visit notes on assigned clients.
• Coordinate health care services provided by ancillary personnel
such as home health aides, medical social work and indicated therapies.
• Coordinate necessary DME and home safety modifications, as needed, to ensure client safety.
• Communicate client health concerns and facilitate follow up appointments to appropriate health care providers.
• Provide client education on disease process management. Obtain labs, perform IV infusions, wound care and treatments, as ordered.
• Utilize EMR systems: Healthwyse, KanTime and Axxess Healthcare.
• Perform health assessments of individuals by evaluating their physical, mental and environmental health status; provided nursing intervention based on assessment of need
• Complete Medicare OASIS assessments and visit notes on assigned clients.
• Coordinate health care services provided by ancillary personnel such as home health aides, medical social work and indicated therapies.
• Coordinate necessary DME and home safety modifications, as needed, to ensure client safety.
labs, perform IV infusions, wound care and treatments, as ordered.
• Communicate client health concerns and facilitate follow up appointments to appropriate health care providers.
• Provide client education on disease process management. medications, infection control, and home safety.
• Utilize EMR systems: Healthwyse and Axxess Healthcare.
• Consistently complied with applicable state and federal laws and regulations and ensured facility adherence to Medicare regulations through training and education.
• Communicated with client’s private health plans or home care management companies to obtain client orders and visit authorizations.
• Supervised, trained and evaluated the performance of nursing staff, therapists and other personnel.
• Hired and trained new employees to home care case
management.
• Responsible for reviewing and ensuring proper record compliance to Medicare standards.
• Utilize EMR system: Axxess
• Provided quality nursing care to a variety of medical/surgical clients including ortho/neuro, post total hip and knee replacement, bariatric post surgical care, cardiac, post CVA recovery, respiratory, and general medical.
• Supervision and coordination of aircraft maintenence including: Day-to-day maintenance and inspections, diagnosing malfunctions and replacing components, detailed inspection and record keeping of aircraft maintenance, training and supervision of Air Force
personnel.
Patient Assessments
Documentation and Charting
Strong Clinical Judgment
Patient education and counseling
Wound Care
Intravenous therapy
Professional Bedside Manner
Honors/Awards:
HCAF (Home Care Association of Florida) Professional Caregiver of the year, 2016.