Clinical Documentation Specialist and Certified Medical Assistant with 20+ years of experience in patient care, medical record review, data abstraction, and EMR navigation. Skilled in extracting, validating, and coding clinical data with strong attention to detail and adherence to registry and compliance standards. Brings a unique blend of hands‑on clinical experience and advanced documentation expertise. Proven ability to support quality initiatives, meet productivity expectations, and work independently in remote environments. Dedicated to improving documentation accuracy and contributing to high‑quality patient data for organizational and registry reporting.
Overview
18
18
years of professional experience
1
1
Certification
Work History
Clinical Quality Coordinator/Lead Certified Medical Assistant
WellMed Medical Management - United Health Group
Denton , TX
03.2008 - Current
Documentation, Quality, & Abstraction Duties:
Abstract clinical information from patient charts with strong attention to detail and accuracy.
Review and validate documentation to ensure completeness and compliance with registry and organizational standards.
Conduct detailed chart audits to support quality improvement and reporting.
Identified documentation gaps, collaborating with providers to enhance accuracy and completeness.
Trained and mentored staff on documentation standards and EMR workflows to ensure accuracy.
Utilize multiple EMR systems to extract structured and unstructured clinical data.
Support providers by identifying missing information and resolving documentation discrepancies.
Ensure strict adherence to HIPAA and organizational confidentiality policies.
Demonstrate consistent reliability and productivity in remote and hybrid environments.
Served as trusted point of contact for escalated patient concerns, resolving issues with professionalism.
Facilitated clinical and patient care responsibilities.
Obtained patient vitals, including blood pressure, temperature, pulse, respirations, SpO₂, height, and weight.
Performed EKGs, administered injections, and assisted with in‑office procedures.
Completed blood draws, specimen collection, and point‑of‑care testing.
Prepared exam rooms, supported patient flow, and ensured a safe, efficient clinical environment.
Provided patient education, follow‑up communication, and compassionate, trauma‑informed support.