VANESSA MONTERO BSN, RN
Miami,FL
Summary
Detail-oriented Registered Nurse with 5+ years of Pre-Anesthesia Testing experience and 2+ years in Med/Surg nursing. Expertise in medical record documentation, patient assessments, and collaborating with interdisciplinary teams for accurate and compliant documentation. Proficient in CPT codes, healthcare regulations, and clinical workflows. Seeking to leverage clinical experience to enhance documentation accuracy and quality in Clinical Documentation Improvement (CDI).
Overview
8
8
years of professional experience
Work History
Pre-Anesthesia Testing Nurse (Remote & On-site)
South Miami Hospital
Miami, FL
06.2019 - Current
- Conduct patient assessments and gather comprehensive medical history for pre-operative documentation before patient's surgery
- Ensure accurate documentation to comply with coding standards and healthcare regulations
- Collaborate with physicians and healthcare teams to clarify patient histories, contributing to accurate and complete records
- Educate patients on anesthesia procedures and ensure documentation of pre-surgical care
- Work with coding teams to ensure documentation supports billing and coding processes
- Serve as Charge Nurse on select occasions, overseeing unit operations and coordinating clinical staff
- Perform patient care audits and ensure that documentation meets compliance with clinical and regulatory standards
- Facilitate communication between nursing staff and physicians to clarify and complete patient documentation
Neurological & Neurosurgery Med/Surg RN
Baptist Hospital
Miami, FL
03.2017 - 06.2019
- Provided bedside care for patients with neurological and neurosurgical conditions, performing assessments, and managing pre and post-operative care.
- Accurately documented patient care, collaborating with interdisciplinary teams to ensure complete and compliant medical records
- Monitored patient progress and facilitated clear communication between care providers, supporting optimal outcomes and regulatory compliance
Education
Bachelor of Science - Nursing
Nova Southeastern University
Kendall, FL12.2016
Skills
- Cerner
- Microsoft Office
- Microsoft Teams
- Medical Record Documentation & Compliance
- Knowledge of CPT Codes & Healthcare Standards
- Pre-Anesthesia Patient Assessment & Documentation
- Chart Review & Data Accuracy
- Regulatory Adherence & Coding Support
- Multidisciplinary Team Collaboration
- Critical Thinking & Problem Solving
- Remote Work Experience
Licenses, Certifications, and Professional Affiliations
- Registered Nurse (RN), #9454117
- Basic life support (BLS)
- American Nurses Association (ANA)
- American Society of PeriAnesthesia Nurses (ASPAN)
Accomplishments
- Magnet Unit Nurse of the Year - 2020
Languages
English
Native/ Bilingual
Spanish
Native/ Bilingual
Timeline
Pre-Anesthesia Testing Nurse (Remote & On-site)
South Miami Hospital
06.2019 - Current
Neurological & Neurosurgery Med/Surg RN
Baptist Hospital
03.2017 - 06.2019
Bachelor of Science - Nursing
Nova Southeastern University
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