CCDS for level I trauma center. Patient population comprised of level I trauma/ multi-trauma adult and pediatric patients.
Also experienced with Cardiac, GI, GU, Burn, Ortho/ OrthoTrauma Neuro, Vascular, and General Surgical patients; Critical Care patients in the NICU, PICU, adult Critical Care Units, Telemetry, and General floor patients.
Queried providers to clarify ambiguous, conflicting, and unclear documentation to the highest specificity and based on the Vizient Risk Model.
Highly proficient using Vizient Risk Model Calculator. Use Solventum (3M-360) and Cerner applications.
Demonstrated leadership skills in managing projects from concept to completion.
Demonstrated strong organizational and time management skills while managing multiple projects.
Goal-oriented professional with proven success in applying analytical skills to solve complex problems and overcome challenges. Dedicated to enhancing team performance and driving business success.
Developed strong communication and organizational skills through working on group projects.
Gained extensive knowledge in data entry, analysis and reporting.
Identified issues, analyzed information, and provided solutions to problems.
Staff CCDS; 2nd Level Reviewer; Trainer
Medovent Solutions
West Palm Beach, FL
08.2023 - 06.2025
First assignment: CCDS in busy level 1 trauma center. Used 3M-360, Cerner. Experienced with Vizient Risk Model.
Second assignment: Conducted 2nd level reviews on AI Pilot Program: SmarterDx and assisted with training staff. Also worked with 3M360 Cerner and Epic software.
CCDS
Cognizant Technology Solutions
Teaneck, NJ
08.2021 - 10.2024
Remote Clinical Documentation Integrity Specialist in Federal and Community Hospitals.
Experienced with working with MS-DRG's, provider education, and preserving and improving the integrity of the patient's chart through helping ensure proper documentation.
Headed up project for auditing charts of all discharged (in)patients with a diagnosis of Pneumonia.
Reviewed all of these patient encounters for possible further specificity of Pneumonia Diagnosis.
Experience with peer, 2nd level reviews, HAC/PSI, and Mortality reviews.
Applications used: Nuance Clintegrity, eCAC, VERA Billing system.
Clinical Documentation Specialist
Optum
Remote
05.2023 - 08.2024
Clinical Documentation Integrity Specialist for busy level I trauma hospital.
Experienced with eCAC, Optum Clintegrity and Epic software.
Experienced in concurrent and retrospective reviews.
Highly experienced with query writing, provider communication, provider and staff education, insurance denials, and mortality reviews.
Resource nurse when Supervisor was off to new and seasoned staff, and helped train new staff when needed.
Experienced with identifying HAC's, PPC's and PSI's.
Utilized APR / DRG system.
Mentored new hires, resulting in stronger staff development and increased productivity.
Clinical Documentation Improvement Specialist: Peer and Provider Education/Training
Ascension Saint Agnes Hospital
Baltimore, MD
01.2017 - 01.2018
Clinical Documentation Improvement Specialist working in large teaching hospital.
Helped bridge transition from Meditech system to 3M 360 application and assisted in training staff to become proficient (as I already had experience using 3M 360).
Utilized APR / DRG system.
Experienced in one on one and group provider education.
Optimized customer experience by delivering superior services and effectively troubleshooting issues.
Evaluated staff performance and provided coaching to address inefficiencies.
Clinical Documentation Improvement Specialist
Prince George Hospital Center
Cheverly, MD
01.2016 - 01.2017
Clinical Nurse Integrity Specialist reviewing physician documentation to ensure documentation conveyed to the highest clarity and specificity.
Queried physicians if documentation was unclear, incomplete or ambiguous.
Assigned APR-DRG's to diagnoses and learned and applied ICD-10 codes to diagnoses for succinct patient documentation and proper hospital reimbursement as needed.
Used 3M-360 application.
Received 12 week extensive on site training program with mentorship.
Registered Nurse in Surgical Services Department
Northwest Hospital Center
Randallstown, MD
01.2011 - 01.2016
RN in Perioperative Services, providing care to the Surgical Patient from Pre-Admission Testing, to PreOping patients for surgery, and caring for the patient emerging from Anesthesia in the Recovery Room.
Cared for Ambulatory patients, 23H stay patients, and ICU patients.
Frequently assumed Charge Nurse role: excellent in conflict resolution.
Commonly assisting entire hospital with difficult IV starts.
ICU Nurse
Maryland General Hospital
Baltimore, MD
01.2009 - 01.2011
ICU Nurse providing total care for patients with single problems to multi-system organ failure.
Care of the ventilated patient and HD patients.
Management of Cardiac output lines and vascular patients.
Registered Nurse
Gilchrist Hospice Care
Towson, MD
01.2008 - 01.2009
RN Case Manager working in home hospice care caring for the terminally ill patient and their families.
Registered Nurse (RN)
Union Memorial Hospital
Baltimore, MD
01.2007 - 01.2008
RN caring for patients in Cardiac Cath Lab Recovery Room.
Recovered patients from conscious sedation and monitored for possible complications during/after invasive procedures and treated them when/if they arose.
Registered Nurse
Mercy Hospital and Medical Center
Baltimore, MD
01.2002 - 01.2004
RN working in the Interventional Radiology Department.
Included caring for outpatients to ICU/multisystem trauma patients.
Administering conscious sedation and monitoring vital signs during Interventional Radiological and Interventional Neuroradiological procedures.
Critical Care Registered Nurse
St Joseph Medical Center
Towson, MD
01.1998 - 01.2002
RN working in different Critical Care areas of the Hospital: Cardiac Catheterization Laboratory, Medical/Surgical Intensive Care Unit, and Post Anesthesia Care Unit.
Critical care Nurse managing the cardiac patient in the Cath Lab.
Included caring for patients with new onset MI's, patients needing defibrillators, and pacemakers while administering conscious sedation of these patients and monitoring respiratory status and vital signs.
Intervened via ACLS protocol during Catheterization Procedures when needed.
Care of the patient including insertion of IV lines, monitoring and reading EKG rhythm and assisting with intervention when necessary with advanced procedures such as PFO Closures, Cardiac and Carotid Stenting, IABP insertion and monitoring, Pericardial Window, EP and ICD/PPM insertion, and monitoring for any lethal ectopy intra and post procedure.
Medical Surgical ICU: Included total care of the critically ill patient in the Intensive Care Unit.
Assisted with procedures such as insertion and monitoring of invasive lines not limited to Endotracheal Intubation, Ventriculostomy insertion and pressure monitoring, PICC and SWAN lines, and titration of vaso-active IV medications.
Timeline
CCDS
Oxford Global Corporation
06.2025 - Current
Staff CCDS; 2nd Level Reviewer; Trainer
Medovent Solutions
08.2023 - 06.2025
Clinical Documentation Specialist
Optum
05.2023 - 08.2024
CCDS
Cognizant Technology Solutions
08.2021 - 10.2024
RN
nThrive, Inc.
12.2018 - 05.2022
Clinical Documentation Improvement Specialist: Peer and Provider Education/Training