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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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