Susan A. Stockard
Huron,OH
Summary
Highly focused RN-CCDS professional with experience in assessing medical records and improving documentation in acute care settings. Collaborative approach with healthcare providers and multidisciplinary teams to promote quality, accuracy, and clarity within the patient record. Seeking remote opportunity as RN-Certified Clinical Documentation Specialist.
Overview
13
13
years of professional experience
Work History
RN CCDS-Remote
Cabell Huntington Hospital (w/Brundage Group)
Huntington, West Virginia
02.2025 - Current
- Conduct detailed daily reviews of patient medical records across a wide range of specialties using Cerner PowerChart and Optum Integrity One to ensure accurate, complete, and compliant documentation.
- Analyze all relevant clinical documentation to determine the principal diagnosis, assign POA/NPOA, and identify documentation gaps or inconsistencies.
- Monitor for diagnoses impacting SOI/ROM, PSI/HAC risk, and quality metrics (e.g., sepsis, AKI, respiratory failure, malnutrition).
- Prepare and submit compliant provider queries that clarify clinical documentation to enhance accuracy, completeness, and quality of the medical record, ensuring correct code assignment and appropriate revenue optimization. Track and follow up on any outstanding provider queries to ensure timely resolution.
- Collaborate with HIM/Coding professionals to ensure accuracy of the final coded chart and reconcile DRG discrepancies or documentation concerns.
- Support initiatives to reduce documentation‑related denials.
- Positively impact the overall patient medical record while adhering to ACDIS code of Ethics and the AHIMA guidelines for Achieving a compliant Query
- Maintain current knowledge of ICD-10 coding guidelines, DRG assignment criteria, and CMS regulations
RN CCDS
MercyOne Medical Center- Dubuque (Remote)
Dubuque, IA
05.2023 - 06.2024
- Performed in-depth reviews of medical records using Cerner PowerChart and 3M 360 to ensure accuracy, quality and completeness of inpatient clinical documentation with occasional cross-coverage to other sites within region
- Analyzed data from multiple sources including ED, H&P, consults, laboratory, radiology, pathology, nursing, ancillary and other applicable documentation to assign the principal diagnosis and appropriate POA/NPOA diagnoses
- Created and submitted Provider queries to facilitate quality, completeness, accuracy and optimal revenue enhancement of the patient's medical record
- Maintained current knowledge of ICD-10 coding guidelines, DRG assignment criteria, and CMS regulations
- Second-level peer reviews at the direction of CDI Supervisor, Coordinator
- Physician education at the direction of CDI Supervisor, Coordinator
- Monitored and reported PSI/HAC to Quality dept
- Collaborated with HIM/Coding professionals to ensure accuracy of final coded data
- Positively impacted the overall patient medical record while adhering to ACDIS Code of Ethics and the AHIMA Guidelines for Achieving a Compliant Query
Travel RN-Utilization Management
Medical Solutions/Medical Center Hospital
Odessa, TX
11.2022 - 02.2023
- See below travel assignment for details
Travel RN-Utilization Management
Medical Solutions/Medical Center Hospital
Odessa, TX
05.2022 - 08.2022
- Utilized XSOLIS Cortex AI software and clinical judgment to determine patient admission status and ongoing medical necessity
- Discussed cases with providers for secondary review due to failure to meet inpatient criteria
- Collaborated with providers to obtain required clinical documentation, supporting prior authorization determinations and individual inquiries
- Collaborated with providers in the peer-to-peer review and denials process
- Monthly denials research and analysis project of top denied DRG's, Excel report creation
- Educated patients regarding Observation status and MCR MOON form
RN, CDI and Utilization Specialist
Firelands Regional Medical Center
Sandusky, OH
04.2018 - 05.2022
- Reviewed medical records to ensure accuracy and completeness of clinical documentation
- Communicated with providers through face-to-face discussion and the creation of queries regarding missing, unclear or conflicting documentation for clarification
- Collaborated with HIM/Coding professionals to ensure the accuracy of final coded data
- Generated monthly CDI reports that reflected overall hospital and individual performance metrics
- Educated physicians regarding clinical documentation integrity via Lunch & Learns, Tip sheets, Take-5 education sessions
- Daily reviews of MCR, managed MCR, traditional insurance and observation patient records utilizing MCG Indicia for continued stay criteria, upgrade to inpatient status
- Team-lead on multidisciplinary Hospital Documentation Standard Definitions project
RN, Case Manager/Utilization Review Nurse
Firelands Regional Medical Center
Sandusky, OH
04.2015 - 04.2018
- Reviewed inpatient admissions to determine medical necessity and cost-effectiveness of services utilizing InterQual criteria and clinical judgement
- Referred cases for secondary review to physician advisor for failure to meet InterQual criteria
- Discharge planning with a multidisciplinary team and community resources
RN Medical Surgical/Tele Charge Nurse/Staff Nurse
Firelands Regional Medical Center
Sandusky, OH
03.2013 - 04.2015
- Cared expertly for individuals with a wide array of diagnoses including pulmonary, cardiology, neurology and infectious disease patients
- Administered treatments, therapies and medication according to prescribed methods and protocols
- Assessed patients using comprehensive evaluation techniques and sound clinical judgment
- Managed operations of talented team of nurses and patient care technicians, verifying proper staffing and allocation of resources within 20-bed medical-surgical floor
Education
CCDS- Certified Clinical Documentation Specialist -
Clinical Documentation Integrity
Akron, OH06-2023
Associate Degree of Nursing Registered Nursing -
BGSU Firelands/Lorain County Community College
12.2012
LPN-IV Licensed Practical Nursing -
Sandusky Career Center
12.2010
Bachelor of Arts Psychology -
Cleveland State University
12.2000
Skills
- Documentation improvement and integrity
- Strong analytical and problem-solving skills
- Independent judgment
- Extensive clinical knowledge
- Attention to detail
- Educator/Trainer
- Flexible and adaptable
- Strong organizational skills
- Ability to work independently and collaboratively
- ICD-10 coding
- Provider queries
- Team collaboration
- Critical thinking
- Proficient in Optum Integrity One, 3M 360, Cerner PowerChart, XSOLIS/Cortex, MCG Indicia, InterQual, Meditech Expanse, ChartWise CDI, Microsoft Outlook, Teams, Word, Excel
Additional Information
- ChartWise CDI- Manager-reporting, Educator/Trainer-Firelands Regional Medical Center
- Utilization Review Committee Member/Contributor-FRMC
- Meditech EHR- Core Team Lead/Builder/Super-user, Educator/Trainer for Case Management/Utilization Review/CDI colleagues-FRMC
- MCG Indicia- Implementation Team, Super-user, Educator/Trainer for Utilization Review colleagues-FRMC
Licenses Certifications Memberships
- Ohio Multistate Compact Nursing License- Expires 10/31/2027
- CCDS-Expires 06/10/2027
- BLS- Expires 09/30/2027
- Association of Clinical Documentation Integrity Specialists-Member
- CDI+ Pocket Guide Unbound Edition by Pinson & Tang-Subscriber
Timeline
RN CCDS-Remote
Cabell Huntington Hospital (w/Brundage Group)
02.2025 - Current
RN CCDS
MercyOne Medical Center- Dubuque (Remote)
05.2023 - 06.2024
Travel RN-Utilization Management
Medical Solutions/Medical Center Hospital
11.2022 - 02.2023
Travel RN-Utilization Management
Medical Solutions/Medical Center Hospital
05.2022 - 08.2022
RN, CDI and Utilization Specialist
Firelands Regional Medical Center
04.2018 - 05.2022
RN, Case Manager/Utilization Review Nurse
Firelands Regional Medical Center
04.2015 - 04.2018
RN Medical Surgical/Tele Charge Nurse/Staff Nurse
Firelands Regional Medical Center
03.2013 - 04.2015
CCDS- Certified Clinical Documentation Specialist -
Clinical Documentation Integrity
Associate Degree of Nursing Registered Nursing -
BGSU Firelands/Lorain County Community College
LPN-IV Licensed Practical Nursing -
Sandusky Career Center
Bachelor of Arts Psychology -
Cleveland State University