Ruth McCormack
Summary
Adept Clinical Documentation Integrity Specialist with a proven track record at Steward Health Care, enhancing documentation accuracy and compliance. Excelled in educational support and software proficiency (MS Excel, Word, PowerPoint), achieving significant improvements in coding and documentation practices. Demonstrated exceptional collaboration and quality assurance skills, leading to a notable $87,000 reimbursement recovery.
Overview
43
43
years of professional experience
Work History
Clinical Documentation Integrity Specialist
Steward Health Care
02.2013 - Current
- Review the medical record concurrent and retrospectively for completeness and accurate documentation.
- Generate compliant queries for documentation clarity, specificity, clinical validation and risk adjustment for accurate coding assignment.
- Collaborate with healthcare providers on documentation issues, provide documentation tips and resolve any query issues.
- Worked with healthcare providers on transition into new EMR query processes.
- Collaborate with coding on resolving mismatch DRG's, poss query opportunities or issues.
- Reconcile final coding accounts for query impact data.
- Attending length of stay meetings and answered and provided information to case management and providers on DRG assignment and potential query opp.
- Developed and presented to staff and providers power point presentations on How DRG assignments are made and Generic documented conditions.
- Held short monthly webinars for providers on CDI tips.
LPN Charge Nurse
Grandview Health Care Center
02.2011 - 02.2013
- Assessed patients' temperature, pulse, and blood pressure and recorded in electronic medical records.
- Managed and documented medications and wound care.
- Provided compassionate end-of-life care, supporting patients and their families.
- Delegated tasks effectively, optimizing staff productivity and maintaining a well-organized nursing unit.
- Assembled and used equipment such as catheters, tracheotomy tubes, or oxygen suppliers to effectively manage patient care.
- Utilized critical thinking skills to make sound clinical decisions in high-pressure situations, minimizing risks and ensuring patient safety.
LPN Office Nurse
The Emory Heart Center
08.2009 - 02.2011
- Developed strong rapport with patients and their families, fostering trust and open communication during sensitive medical situations.
- Assisted in maintaining a clean and organized office environment by performing housekeeping tasks such as disposing of biohazardous waste, sanitizing exam rooms, and restocking supplies as needed.
- Assisted with minor surgical procedures, ensuring proper sterilization techniques and adherence to safety protocols.
- Coordinated referrals to specialists when necessary, ensuring seamless transitions of care for patients within the healthcare system.
- Served as a liaison between patients and healthcare providers, facilitating clear communication regarding treatment plans and expectations.
- Provided health education to patients on various topics such as medication management, disease prevention, and self-care strategies.
- Conducted thorough assessments of vital signs, lab results, and physical status to identify potential concerns and inform appropriate interventions.
- Prepared patients for diagnostic testing procedures by explaining the process, providing reassurance, and answering any questions they may have.
LPN Nursing and Coordinator of Cardiology Practice
Osler Medical Group
07.1986 - 06.2009
- Utilized time management skills to prioritize tasks effectively, allowing for efficient completion of daily responsibilities.
- Maintained accurate documentation of all relevant clinical data, ensuring compliance with regulatory standards.
- Implemented infection control measures, ensuring a clean and safe environment for patients and staff.
- Managed patient care through closely monitoring respiration, blood pressure, and blood glucose levels.
- Administered controlled narcotics, inserted IVs, and performed catheterizations. Assisted in EKG monitoring, adenosine, Echo and nuclear stress testing, transesophageal bubble studies, and cardioversion.
- Studied and Coordinated and started EECP program for the facility.
- Audited 3 years of medical records that were denied by BCBS that resulted in $87,000 reimbursement back to the facility.
- Coordinated and attended hospital rounding of patients assisting in compiling medical records, diagnostic and lab results, Assisted with admissions, appointments, transfers, and discharges.
- Handled and filled out various forms for patients: social security disability, FMA, dural medical equipment , return to work.
- Coordinated with the billing/insurance at facility on Providers inpatient and outpatient accurate coding and wrote letters of necessity on diagnosis and diagnostic and lab tests.
LPN Office Nurse
Dr. Siddiqui
08.1982 - 07.1986
- Developed strong rapport with patients and their families, fostering trust and open communication during sensitive medical situations.
- Improved patient experience by providing compassionate and attentive nursing services in a busy office setting.
- Assisted in maintaining a clean and organized office environment by performing housekeeping tasks such as disposing of biohazardous waste, sanitizing exam rooms, and restocking supplies as needed.
- Assisted with minor surgical procedures, ensuring proper sterilization techniques and adherence to safety protocols.
- Coordinated referrals to specialists when necessary, ensuring seamless transitions of care for patients within the healthcare system.
LPN
Holmes Regional Medical Center
08.1981 - 08.1982
- Utilized time management skills to prioritize tasks effectively, allowing for efficient completion of daily responsibilities.
- Maintained accurate documentation of all relevant clinical data, ensuring compliance with regulatory standards.
- Implemented infection control measures, ensuring a clean and safe environment for patients and staff.
- Managed patient care through closely monitoring respiration, blood pressure, and blood glucose levels.
- Worked with nursing supervisor on administering medications and wound care.
Education
Certification - Clinical Documentation Specialist
ACDIS
Middleton11.2016
Certificate - Anatomy And Physiology ICD-10-CM And ICD-10-PCS
Presyse University
Melbourne, FL10.2013
Advanced Life Support Certification -
Holmes Regional Medical Center
Melbourne, FL07.1989
Diploma For Practical Nursing - Practical Nursing
Florida Hospital School of Practical Nursing
601E Rollins ST, Orlando, FL 3280308.1981
High School Diploma -
Melbourne High School
Melbourne, FL06.1977
Skills
- Proficient in multiple software programs including MS excel, Microsoft, Word and Power Point, Iodine and Interact
- Knowledgeable in medical terminology, coding and practice guidelines
- Documentation Management
- Quality Assurance
- Educational support
Timeline
Clinical Documentation Integrity Specialist
Steward Health Care
02.2013 - Current
LPN Charge Nurse
Grandview Health Care Center
02.2011 - 02.2013
LPN Office Nurse
The Emory Heart Center
08.2009 - 02.2011
LPN Nursing and Coordinator of Cardiology Practice
Osler Medical Group
07.1986 - 06.2009
LPN Office Nurse
Dr. Siddiqui
08.1982 - 07.1986
LPN
Holmes Regional Medical Center
08.1981 - 08.1982
Certification - Clinical Documentation Specialist
ACDIS
Certificate - Anatomy And Physiology ICD-10-CM And ICD-10-PCS
Presyse University
Advanced Life Support Certification -
Holmes Regional Medical Center
Diploma For Practical Nursing - Practical Nursing
Florida Hospital School of Practical Nursing
High School Diploma -
Melbourne High School
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