Susie Lucinario, BSN, RN

Nutley, NJ 201-***-**-** ad1lic@r.postjobfree.com www.linkedin.com/in/susielucinario PROFESSIONAL SUMMARY Job Target - Clinical Documentation Improvement Specialist

Compassionate and self driven Registered Nurse with 13 years experience in variety of health care setting. Seeking remote/hybrid/on site nurse opportunity in the role of RN Case Management, RN -Utilization Review, or RN CDI- Specialist, Nurse Researcher, Informatics Nurse, HEDIS abstractor

● Five years in acute care hospital setting in telemetry/ medical surgical unit in a teaching hospital as a staff nurse

● Two years of Psychiatric Nursing in Dual Diagnosis Unit as Charge Nurse

● Two years in Hospice and Palliative Care as Hospice Case Manager

● Four years in Long Term Care and Sub acute Rehab as staff nurse, unit manager and weekend shift supervisor.

KEY SKILLS

● ACDIS approved CDI apprenticeship program

● Utilization Review

● Case Management

● Clinical Documentation

● Electronic Medical Records: Cerner, EPIC,

● Lean Six Sigma Foundations

PROFESSIONAL EXPERIENCE

RN STAFF Saint Michael’s Medical Center Newark NJ 09/2018 -present

● Staff nurse fulfilling roles of primary bedside nurse and rotational charge nurse assignment on 32 bed surgical and telemetry unit.

● Demonstrated proficiency in navigating and utilizing Electronic Health Record (EHR) systems EPIC

, ensuring accurate and timely documentation of patient information, treatment plans, and assessment, while maintaining strict adherence to privacy and security protocols.

● Skilled in the management of acute and chronic conditions including COPD, CHF, Renal Failure Sepsis in the telemetry unit

● Actively contributed to Case Management and Discharge Planning processes by collaborating with case managers and healthcare providers, ensuring comprehensive assessments, facilitating patient education, and coordinating post discharge resources and continuity of care (ensure that services that patient will need at home, ensures patient’s prescription are filled / sent to their pharmacy, discharge instruction/education is given and to follow up for outpatient appointments)

● Demonstrated exceptional leadership skills as charge nurse, effectively delegating tasks, and providing guidance and support to nursing staff to ensure delivery of high quality patient care in a fast paced environment

Charge Nurse Dual Diagnosis Unit Summit Oaks Psychiatric Hospital Summit, NJ 08/2017 - 01/2019

● Conducted nightly chart audits

● Administers medication for withdrawal of alcohol and substance abuse and treatment protocols, monitored patients’ CIWA and COWS, and documentation utilizing electronic medication administration record.

● Responds to crisis intervention in collaboration with nursing staff and mental health workers to de escalate agitated patients and diffuse volatile situations

● Receives physician orders for direct admissions and organizes admission process for patient and assess patient’s level of care needs

Hospice Case Manager VNAHG/Barnabas Health Hospice West Orange, NJ 04/2015-08/2017

● Assess patient’s eligibility to hospice program based on LCD medicare guidelines to ensure appropriateness, knowledgeable on ICD 10 and HCPS codes related to hospice and collaborates with Medical Director to deem appropriateness of patient to the program

● Manage the care of 15-20 terminally ill patients, including pain regimen management and evaluation, symptom management in patients’ homes or facilities, medication administration and observation of adverse reaction

● Document patients’ trajectory decline, determining eligibility to hospice and assessing ongoing appropriateness to hospice per Medicare guidelines

● Provide bereavement resources and emotional support to family members during end of life Staff Nurse RN Alaris Health at Belgrove Kearny, NJ 10/2013- 04/2015

● Provided clinical care for a wide range of patients, including sub-acute, hospice and long-term care geriatric patients

● Additional duties include pain management, assessments, medication pass, treatments, admissions, discharges, IV therapy, trach care, colostomy care, wound care, wound vacs, dressing changes, oxygen therapy, nebulizers, BIPAP, CPAP and taking accurate documentation

● Educated patients and family members on disease processes and prevention Unit Manager Alaris Health at Belgrove Kearny, NJ 10/2013- 04/2015

● Part of Interdisciplinary assisting Utilization committee and with concurrent reviews for patients to ensure that extended stays are medically justified, and are reflected in patient’s medical records

● Reviewed clinical records for completeness and accuracy and monitored, tracked, evaluated and reported infections for the unit

● Collaborated with Director of Nursing to identify and provide orientation and education for unit staff members Shift Supervisor Alaris Health at Belgrove Kearny, NJ 04/2013- 04/2015

● Served as administrative authority to ensure seamless operations in all units on assigned shift

● Alerted administrator, associate administrator, head nurse or manager of urgent concerns

● Communicated non-urgent concerns to manager via phone message or email

● Received employee, resident and family grievances and referred to appropriate department

● Worked with staffing schedule and nurse managers to ensure vacancies are filled in advance Staff RN Sub acute Unit and Long Term Care Unit Care One at Wellington Hackensack, NJ 04/2011- 04/2015

● Cared for 21-22 patients in sub-acute and facilitated patient admissions, transfers and discharges

● Delegated tasks to team of 4-5 nursing assistant staff members

● Completed physician orders of medication and treatment with cases involving rehabilitation, hospice, TPN, use of peripheral, midline and PICC line for IVT, tracheostomy, colostomy, GT/PEG feeding, wound vac therapy and management, dementia/Alzheimer’s care

Staff RN New York Center for Nursing and Rehab Queens, NY 11/2010- 04/2011

● Consulted and coordinated with healthcare team members to assess, plan,implement or evaluate patient care plans

● Maintained accurate and detailed reports and records

● Monitored all aspects of patient care, including diet and physical activity

● Administered medications to patients and observed patients for reactions or side effects SKILLS/TRAINING

ACDIS-approved CDI apprenticeship Certificate program November 2023

● Introduction to CDI: Core Concepts and Professional Skills: Defines the roles and responsibilities of the CDI profession and explains its value to the healthcare system

● Understanding the DRG and IPPS Systems: Describes how to assign MS- and APR-DRGs, how hospitals are paid under the IPPS, and the nuances of the Medicare reimbursement system.

● Coding Essentials for the CDI Specialist: Provides an overview of principal diagnosis, reportable secondary diagnoses, and ICD-10. Also includes a brief concept overview of present on admission and hospital-acquired conditions.

● Conducting the Health Record Review: Describes how CDI professionals should interrogate the medical record, identifying which sections are most important, which documentation can be used for coding vs. querying, and where to find clinically relevant data.

● Introduction to Queries and the Query Process: Provides guidance on how to formulate an effective, compliant query, and reviews major industry developments in query standards and compliance guidance.

● Documentation Requirements for Sepsis: Explains the difference between SIRS and sepsis, identifies clinical indicators for sepsis, and discusses the AHA sepsis coding guidelines.

● Documentation Requirements for CHF: Differentiates between heart failure type and acuity, and explains the AHA coding guidelines for heart failure.

● Documentation Requirements for Acute Respiratory Failure: Identifies the clinical indicators and explains AHA coding guidelines for respiratory failure.

● Documentation Requirements for Malnutrition: Differentiates between the types of malnutrition, identifies the diagnostic characteristics for adult malnutrition, and explains the AHA malnutrition coding guidelines.

● AHIMA/ACDIS Guidelines for Achieving a Compliant Query Practice

● ACDIS Code of Ethics

LICENSES AND CERTIFICATIONS

Registered Nurse (RN) New Jersey State Board of Nursing, expires 05/2025 ACDIS-approved CDI apprenticeship Certificate program National Institute of Health Stroke Scale Certification, expires 06/2025 Basic Life Support (BLS) American Heart Association, expires 03/2024 Advance Cardiac Life Support (BLS) American Heart Association, expires 03/2024 EDUCATION

Bachelor of Science in Nursing (BSN), Manila Doctors College Pasay City Paranaque Philippines 2009

Contact this candidate