Maryann Wheeler
Lanoka Harbor,NJ
Summary
Experienced Clinical Documentation Specialist with background in healthcare settings. Demonstrated mastery of medical terminology, coding fundamentals, and compliance requirements. Strengths include critical thinking, process improvement strategies and strong interpersonal communication skills. Previous roles involved enhancing clinical documentation processes for accuracy, leading to improved quality of patient care and streamlined operations.
Overview
33
33
years of professional experience
1
1
Certification
Work History
Clinical Documentation Specialist
RWJBarnabas Health
Oceanport, NJ
09.2014 - Current
- Maintained current knowledge of ICD-10 coding requirements, CPT and HCPCS coding systems, DRG assignment criteria and CMS regulations.
- Uncovered discrepancies in health records and contacted physicians to provide further documentation to clarify concerns.
- Identified discrepancies in documentation with providers and resolved inconsistencies in a timely manner.
- Developed strategies designed to improve quality outcomes associated with specific diagnosis groups.
- Participated in regular meetings with physicians, nurses, case managers, coders, therapists. to discuss changes or improvements needed for clinical documentation processes.
- Monitored compliance with regulatory standards for the Clinical Documentation Improvement program.
- Maximized accuracy and completeness of medical records through in-depth audits and patient information reviews.
- Created educational materials related to best practices for accurate clinical documentation across all settings.
- Demonstrated knowledge of HIPAA Privacy and Security Regulations by appropriately handling patient information.y.
- Reviewed medical records to ensure accuracy and completeness of clinical documentation.
- Acquired strong background in medical terms, illnesses and conditions and medical procedures.
- Advised staff members regarding appropriate use of modifiers when applicable.
- Utilized various software and tools to streamline processes and optimize performance.
- Provided support and guidance to colleagues to maintain a collaborative work environment.
- Managed time effectively to ensure tasks were completed on schedule and deadlines were met.
- Conducted testing of software and systems to ensure quality and reliability.
- Demonstrated strong problem-solving skills, resolving issues efficiently and effectively.
- Maintained updated knowledge through continuing education and advanced training.
Assistant Director of Patient Care
Community Medical Centers
Toms River , NJ
02.2009 - 09.2014
- Oversaw employee relations issues such as grievances, disciplinary actions and terminations.
- Remained calm and professional in stressful circumstances and effectively diffused tense situations.
- Coordinated daily operations and managed workflow to enhance productivity.
- Conducted performance evaluations and recommended areas for improvement.
- Interviewed prospective employees and provided input to HR on hiring decisions.
- Assigned work and monitored performance of project personnel.
- Organized team activities to build camaraderie and foster pleasant workplace culture.
- Ensured compliance with safety regulations among all personnel.
- Supervised junior staff, providing guidance and professional development opportunities.
- Completed thorough opening, closing, and shift change functions to maintain operational standards each day.
- Delegated work to staff, setting priorities and goals.
- Resolved customer inquiries and complaints requiring management-level escalation.
- Provided leadership, insight and mentoring to newly hired employees to supply knowledge of various company programs.
Staff Nurse
Community Medical Centers
Toms River , NJ
10.1991 - 02.2009
- Monitored patient vitals post-surgery, managed medical equipment, and administered medications and IVs.
- Utilized an electronic medical record system to store patient information securely.
- Evaluated the effectiveness of nursing interventions and modified plans as needed.
- Coordinated discharge planning to ensure continuity of care post-hospitalization.
- Addressed rapid response and code situations by strategically organizing and delegating tasks.
- Assessed patient conditions, monitored behaviors and updated supervising physicians with observations and concerns.
- Evaluated patients to develop and update treatment plans while anticipating day-to-day needs.
- Helped patients and families feel comfortable during challenging and stressful situations, promoting recovery and reducing compliance issues.
- Provided direct patient care including wound dressing, administering medication and IV therapy.
- Collaborated with interdisciplinary team members to develop plans of care for patients.
- Adhered to strict confidentiality policies when dealing with sensitive information.
- Observed strict safety measures, including checking medication dosages before administration to patients.
- Coordinated care with charge nurse and other staff through daily communication.
Education
Master of Science - Nursing Informatics
Walden University
Minneapolis, MN08-2021
Associate of Science - Nursing
Ocean County College
Toms River, NJ05-1991
Skills
- Training and mentoring
- Exemplary communication skills
- Documentation improvement
- Skilled in Epic
- Skilled in nuance
- Skilled in 3M
- Clinical documentation management
- Medical terminology
- Documentation compliance
- Healthcare staff interaction
- Continuous learning attitude
- Software application proficiency
- Problem-solving capacity
- Multitasking efficiency
- HIPAA regulations
Certification
- NJ Registered Nurse
- Certified Clinical Documentation Specialist (CCDS)
References
References available upon request.
Timeline
Clinical Documentation Specialist
RWJBarnabas Health
09.2014 - Current
Assistant Director of Patient Care
Community Medical Centers
02.2009 - 09.2014
Staff Nurse
Community Medical Centers
10.1991 - 02.2009
Master of Science - Nursing Informatics
Walden University
Associate of Science - Nursing
Ocean County College
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