Teresa Henson
Amboy,IL
Summary
Knowledgeable and experienced Clinical Documentation Improvement Specialist with over three years of expertise in the field. Demonstrates a profound understanding of medical documentation standards, consistently ensuring accuracy and compliance through collaboration with coding professionals. Exceptional analytical and critical thinking abilities contribute effectively to improving documentation practices within the healthcare industry.
Overview
39
39
years of professional experience
1
1
Certification
Work History
Lead CDI/UM Specialist
Katherine Shaw Bethea (KSB) Hospital
11.2002 - Current
- Daily review of inpatient medical records during patient stays to identify and resolve documentation discrepancies in the hospital's designated clinical documentation system
- Collaborate with healthcare providers, case managers, and coders to ensure accurate and comprehensive health record documentation reflecting clinical treatments, decisions, diagnoses, and interventions
- Engage with physicians to resolve ambiguous, incomplete, or conflicting documentation for enhanced clarity and accuracy
- Possess comprehensive anatomy, physiology, disease processes, medical terminology, and pharmacology knowledge
- Accurately assign diagnosis codes by IDC-10-CM standards
- Manage follow-up on queries to ensure timely responses from physicians and proper documentation of those responses
- Collaborate with Health Information Management (HIM) and coding professionals to scrutinize problematic cases and verify the accuracy of coded data in coordination with Clinical Documentation Improvement (CDI) and coding managers
- Perform concurrent reviews of clinical information to enhance patient care efficiency
- Coordinate with healthcare teams to manage and plan patient discharge processes
- Continuously review precertification requests to confirm medical necessity
- Foster a positive work environment, willingly undertaking additional responsibilities as needed to support organizational objectives
- Thrive in a high-pressure, fast-paced environment, operating effectively with minimal supervision
- Maintain exceptional organizational skills and excel in interpersonal communication across various settings.
Office Nurse/Private Surgical Scrub
CGH Medical Center
07.1985 - 11.2002
- Delivered comprehensive patient care and coordinated with healthcare teams to ensure seamless service delivery
- Educated patients on health management and treatment plans, enhancing their understanding and compliance
- Administered medications accurately and safely, adhering to strict medical protocols
- Executed clinical tasks as directed by physicians, ensuring high standards of care
- Managed office operations and collaborated effectively with team members to optimize clinic efficiency
- Maintained a sterile environment in the operating room to uphold safety and hygiene standards
- Demonstrated expertise in surgical instruments, preparing them meticulously for procedures
- Provided critical support to surgeons during operations, assisting with various surgical tasks.
Education
Diploma - Registered Nurse
Rockford Memorial School of Nursing
Rockford, ILSkills
- Teamwork
- Self Motivation
- Problem-Solving
- Multitasking
- Attention to Detail
- Organizational Skills
- Excellent Communication
- Decision-Making
- Reliability
- Adaptability
- Time management abilities
- Professionalism
- Interpersonal Skills
- Customer Relations
- Documentation Management
- Multitasking Abilities
Certification
Accredit Case Manager - RN
Timeline
Lead CDI/UM Specialist
Katherine Shaw Bethea (KSB) Hospital
11.2002 - Current
Office Nurse/Private Surgical Scrub
CGH Medical Center
07.1985 - 11.2002
Diploma - Registered Nurse
Rockford Memorial School of Nursing
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