Experienced RN specializing in clinical documentation and patient care. Known for attention to detail and effective collaboration with healthcare teams to improve documentation accuracy and support optimal patient outcomes. Dedicated Clinical Documentation Integrity RN with proven skills in medical record review and compliant physician queries. Committed to enhancing documentation quality and regulatory compliance.
Overview
20
20
years of professional experience
Work History
Clinical Documentation Integrity (CDI) RN
Conifer Health Solutions (St. Luke's Health)
The Woodlands, Texas
11.2024 - Current
Reviewed medical records to obtain physician documentation for clinical conditions and procedures, ensuring accurate representation of severity of illness, risk of mortality, and complexity of patient care.
Issue compliant physician queries to clarify diagnoses and severity of illness.
Conduct concurrent chart reviews to ensure accurate clinical documentation and appropriate DRG assignment.
Collaborated with physicians, coders, and multidisciplinary teams to enhance documentation accuracy and uphold quality metrics, supporting reimbursement integrity.
Continuously enhance clinical documentation expertise through education and training
RN, Medical-Surgical Telemetry
St. Luke's Health
The Woodlands, Texas
12.2021 - 11.2024
Serves as Relief Charge Nurse (night shift) in a 29-bed MS Telemetry Unit.
Contributed to Unit Based Council and participated in Hospital's Monthly Skin Audit to enhance patient care standards.
Delivered direct patient care to support recovery and promote positive clinical outcomes.
Collaborated effectively in diverse, multi-cultural environment to improve team cohesion and patient satisfaction.
RN, Surgical/Oncology/Neurology
Decatur Memorial Hospital
Decatur, Illinois
04.2018 - 11.2021
Coordinated staffing and patient assignments as Charge Nurse during shift to ensure optimal care delivery.
Preceptor to newly hired RN's
Provided direct bedside care and nursing procedures to enhance patient outcomes and comfort.
Communicated effectively with patients to facilitate understanding of treatment plans and promote engagement.
Staff Nurse
King Abdulaziz Medical City
Riyadh, Saudi Arabia
06.2011 - 05.2018
Provides direct patient care utilizing the nursing process within established hospital, divisional, and unit specific policies and procedures, standards, protocols.
Demonstrates effective communication and collaboration skills when interacting with patients/families, other health care team members and staff of other departments.
Acts as a preceptor and /or resource for new employees, trainees, and other staff.
Participates in teaching and mentoring of Nursing, Medical, interns and residents.
Staff Nurse
King Fahd Armed Forces Hospital
Jeddah, Saudi Arabia
03.2009 - 02.2011
Delivered comprehensive care to general surgery, neuro surgery, urology, ENT, plastic surgery, vascular, orthopedic, ophthalmic, trauma, and maxillofacial patients, ensuring optimal recovery.
Documented patient progress notes, administered medications, and tracked relevant data to support accurate treatment plans.
Monitored patient vitals post-surgery, managed medical equipment, and administered medications and IVs.
Facilitated clear communication among patients, families, physicians, and healthcare staff to enhance patient understanding and care coordination.
Staff Nurse
Iloilo Doctor's Hospital
Iloilo, Philippines
11.2005 - 09.2008
Monitored patient vital signs, promptly reporting changes to medical staff to facilitate timely interventions.
Administered medications and treatments, ensuring adherence to physician's orders and patient safety.
Assisted in developing patient care plans with interdisciplinary teams.
Collaborated with healthcare professionals to develop strategies that enhanced patient outcomes.
Educated patients and families on health management and recovery options.
Education
Bachelor of Science - Nursing
Central Philippine University
Philippines
04-2005
Skills
Skilled in comprehensive medical record review, identification of documentation opportunities, and development of compliant physician queries to ensure accurate clinical documentation
Experienced in analyzing clinical indicators, laboratory results, and diagnostic findings to support appropriate diagnosis capture and CC/MCC identification
Demonstrate strong collaboration with physicians, coders, and interdisciplinary teams to improve documentation quality, regulatory compliance, and reimbursement accuracy
Ability to precept and support new CDI team members