RN, BSN, CCDS
Resume:
Catherine S., RN, BSN, CCDS
Mentone, CA
SUMMARY
• Availability: Two weeks notice
• Years of experience: CDI - 10 years Nursing - 16 years
• Units/Clinical Strengths: ICU, CCU, Surgery, Medical, Telemetry, Neurology, Oncology, Urology, Ortho, Vascular, NICU, Peds, Trauma
• Systems Experience: Navigant, FTI, JATA Nuance, Midas, Cerner, 3M Encoder, Iodine, Epic, Meditech
• Environment: 300 Beds to Large Teaching Trauma Hospitals EXPERIENCE
07/2020-Present
COVID Relief Arrowhead Regional Hospital
01/2020 – 6/2020
Clinical Documentation Specialist
Medovent Solutions through JATA
UCSF Medical Center 1/2020-3/2020
St. Francis, OK 3/2020-6/2020
08/2017- 01/2020
Clinical Documentation Specialist
Medpartner HIM
UCSF Medical Center 08/2017- 11/2017
Kaiser Northern California 1/2018-12/2018
Providence 11/2017-present
University of California Irvine 2/2019-5/2019
• Facilitate comprehensive medical record review in collaboration with the medical record accuracy and compliance with clinical outcomes and evidence-based reporting
• Review 25 to 30 charts per day
• Meet query rate of 25 percent at client with agree rate 98%
• Physician education
• Interact and work with coding department on a daily basis
• Training in and daily capture of HCC for Pediatrics, NICU, and General Population for 20 different facilities across the entire Northern California Kaiser system. 2013 – 2017
Clinical Documentation Specialist
San Antonio Regional Hospital
• Accurate assignment of MS-DRG and APR-DRG
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• Maximization of SOI and ROM for SR HMO and Medicare populations
• Extensive Knowledge of ICD-10
• Ability to articulate clearly through query with positive results
• Contributor in RAC Audit denials for UR and coding purposes
• RAC committee participate who actively reviews denials, as well as strengthens and makes recommendations for appeals
• Assimilated and developed goals for CDI program improvement through statistical review
• Interviewed CDI software designers and participated in selection of CDI software
• Responsible for 85% physician response rate and 200,000K per month in query revenue
• Presenter for CDI education to orthopedic, Cardiac and ER physician committees
• Taught one on one physician documentation education and CDI awareness program
• Frequent review of intensive care, med-surgical, Neurology, and Oncology floors senior and Medicare charts
• Daily review of critical care, telemetry, orthopedic floors senior and Medicare charts
• Conduct mortality chart review for maximum reimbursement, ROM/SOI scores and excellent health grades reports
• Works closely with physician advisor on complex cases and individual physician education needs
• Selected as Beta test participant for CDI software and recommended program feedback features for upgrades and final program version
• Participated in a biweekly ACDIS radio podcast
• ACDIS convention 2014 participant
• Coordinated and created monthly physician documentation education fliers including various topics
• Development, training, and mentoring of new CDI team members
• Regularly conduct statistical analysis of CDI reports
• Participated in daily case management rounding with physician advisor
• Reviewing medical record for medical necessity
• Extensive review and execution of 2-midnight rule
• Authorizing hospital to hospital transfer
• Facilitating communication between CDI and case management 2010 – 2011
Loma Linda University Medical Center
Home Health Nurse
• Exceeded Medicare standards of documentation for Oasis documentation
• On all home Health RN
• Extensive work in wound care for patients
• Present disease specific education to patients’ specific needs
• Thorough documentation and follow up on patients’ specific needs
• Worked independently to create care plans, manage care, disease processes, demonstrated medical supplies and apparatuses, and problem solved health issues
• Effective ability to diplomatically negotiate compassionate and dignified care in various care in various cultures and settings
• Recognized the need for additional therapies such as OT, PT, SW and other various medial interventions
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2009 - 2009
St. Mary Medical Center
Clinical Documentation Specialist
• Member of the CDI staff reviewing Medicare and SR HMO populations
• Launched and participated in CDI awareness campaign
• One on one physician education on CDI concepts
• Initiated Sepsis education for CDI and patient safety 2005 - 2009
St. Mary Medical Center
Staff Nurse/ICU
• Recovered patients pre/post anesthesia, monitoring all elements of care plan
• Recovered patients for post operation cardiac/thoracic surgery
• Proficient in: IV gtt therapy, swan-ganz monitoring/care, care planning, tele monitoring, and wound care.
• Nominated chair-person for ICU unit base committee
• St. Mary Medical Center skills fair instructor
• Educator for new-grad program specializing in endocrinology
• Model for marketing campaign
• Interview panel member for clinical staff member
• Extensive 1:1 training with Navigant Consultant Nurse Practitioner
• Participated in Change Processing Committee
• Internship in Risk Management
• Implemented medication reconciliation unit wide
2002- 2004
St. Bernardine Medical Center
Mother and Baby Nurse
• CNA for pediatrics, MedSurg, and mother baby units
• Daily responsible for intake and output monitoring, weights, bathing, feeding needs, vital signs, infant care, breastfeeding education and RN assistance as needed
• Participant in Joint Commission inspection
EDUCATION
California State Science in Nursing
• Bachelor: Science in Nursing, 2004
LICENSURE AND CERTIFICATIONS
• ACDIS- (CCDS)
• California Board of Nursing- (RN)
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