Experienced Clinical Documentation Specialist dedicated to improving documentation standards across clinical departments. Known for strong teamwork and multitasking abilities, contributing to accurate coding, documentation and communication.
Overview
24
24
years of professional experience
Work History
Clinical Documentation Specialist
Ascension Genesys Hospital/Henry Ford
Grand Blanc, MI
08.2022 - Current
Ensured compliance with documentation standards and regulatory requirements across clinical departments.
Reviewed clinical records for accuracy and completeness, facilitating improved patient care outcomes.
Collaborated with healthcare providers to optimize documentation processes and enhance workflow efficiency.
Communicated with physicians, nurses and other caregivers to explain importance of accurate and clear documentation.
Maintained strong knowledge of medical terminology, diseases and conditions and procedures.
Managed electronic clinical documentation and uploaded changes or updates using CDE 1, Allscripts, Cerner, GEMS, Midas and 3M.
Communicated with coders to ensure that the chart has the correct codes, diagnoses and procedures.
Case Manager
Ascension Genesys Hospital
Grand Blanc, MI
08.2017 - 08.2022
Collaborated with physicians, dieticians, speech therapy, physical and occupational therapy to ensure quality care and lower length of stays
Maintained accurate documentation on all cases, ensuring compliance with regulations and confidentiality requirements.
Reduced client wait times for service access by optimizing internal referral processes.
Streamlined case documentation procedures, reducing processing time and increasing efficiency.
RN Floor Nurse Critical Care and ICU
Ascension Genesys Hospital
Grand Blanc, MI
01.2002 - 08.2017
Fast pace critical thinking
Collaborating with physicians over care plans with pts, lab and test results with treatments and treating diagnoses.
Interpreting lab results and imaging
Understanding diagnoses and the medications and treatments for them