RUBEN RIVERA

Edinburg, TX ***** 956-***-**** adu3k7@r.postjobfree.com

Professional Summary

Highly skilled career bilingual professional with close to 20 years of nursing experience in various settings such as a medical office, clinic, hospital, and home health. I also have over 10 years experience of quality assurance and chart auditing with strong attention to detail and very good analytical skills to keep compliance with CMS, Medicaid, and ORR. Highly skilled with strong computer skills. Proficient with typing, referrals, making appointments, collaborating with Doctors and nurses, using a fax machine, scanning, knowledgeable using Microsoft office products such as Word and Excel. Knowledgeable when operating and using Visionlink, UAC Portal, maintaining immunization records and inputting them into IMMTRAC, Kinnser, PointClickCare (PCC), AXXESS, and HCHB. Spanish/English speaking professional with close to 20 years of experience as an effective advocate for patients.

Professionally trained LVN with experience ensuring high standards of culturally competent care for wide variety of patients with diverse needs.

Skilled performing assessment, education regarding diagnosis, medications and ordered treatments, lab work, documentation with care plan for diagnosis, and administration of treatments procedures. Experience in setting up vaccination clinics for all immunizations required by State, knowledgeable in handing and keeping immunizations as required by Government State agencies.

Computer skilled managing heavy daily patient volume which includes telephonic triaging, appointment scheduling, and patient referral. Proficient in all documentation/record maintenance/paperwork to ensure accuracy and patient confidentiality. Work History

LVN 01/1997 to 02/2007

Christus Spohn Alice Hospital

Worked with multidisciplinary team to carry out successful treatment plans for diverse acute and chronic conditions.

Responded to patient requests with appropriate clinical and personal assistance. Delivered oral medications, intramuscular injections and IV fluids to mitigate or resolve patient symptoms in a Medical Surgical/Telemetry Unit.

Took samples such as blood and urine to complete diagnostic and routine assessment tests. Assessed patients' temperature, pulse and blood pressure and recorded in electronic medical records.

Documented patient vitals, behaviors and conditions to communicate concerns to supervisor . Helped long-term care residents with bathing, dressing, feeding and other daily living activities. Documented patient information obtained from interviews concerning symptoms, medications and prior treatment.

Protected patients and healthcare team members from infection by sterilizing equipment and reusable supplies.

Supported diagnoses by taking blood, urine or sputum samples from patients for laboratory testing.

Clearly and thoroughly explained diagnoses, treatment options and procedures to patients and loved ones, checking in to verify understanding. Reviewed patient history to verify conditions and current medications. Circulated assigned floor to measure and record patients' fluid and food levels, implementing measures to promote healthy intake and output as necessary. Helped patients complete day-to-day tasks, including bathing, dressing and eating. Contributed to committees in effort to promote standardize practices and procedures across hospital-wide nursing stations.

Collaborated with Physicians on evaluation of care plan outcomes, implementing or adjusting interventions accordingly.

LVN 02/2008 to 02/2010

Palm Valley Home Health Care

Performed chart audits and quality assurance checks on all patient records to be in compliance with CMS/Medicaid guidelines.

Was able to communicate effectively with providers and nurses to ensure all medical information is accurately captured in patient's medical record. Strong written and oral communication skills.

Knowledgeable and familiar with medical terminology. Provided complete care to home health patients, including physical assessments, medication and chronic disease management.

Delivered oral medications, intramuscular injections, insulin, and IV fluids to mitigate or resolve patient symptoms.

Managed patients recovering from medical or surgical procedures, including facilitating wound care, ostomy care, pressure ulcer prevention and pain management. Followed all personal and health data procedures to effectively comply with HIPAA laws and prevent information breaches.

Worked with multidisciplinary team to carry out successful treatment plans for diverse acute and chronic conditions.

LVN 01/2011 to 01/2013

Dulce Esperanza Home Healthcare

Reviewed, Qa'd, and performed chart audits for completion and accuracy of patient medical records as per CMS/Medicaid guidelines.

Reviewed patient records to ensure all orders, referrals, labs, or necessary items were properly documented as per CMS/Medicaid guidelines.

Worked with multidisciplinary team to carry out successful treatment plans for diverse acute and chronic conditions.

Delivered oral medications, intramuscular injections and IV fluids to mitigate or resolve patient symptoms.

Documented patient information obtained from interviews concerning symptoms, medications and prior treatment.

Assessed patients' temperature, pulse and blood pressure and recorded in electronic medical records.

Took samples such as blood and urine to complete diagnostic and routine assessment tests. Clearly and thoroughly explained diagnoses, treatment options and procedures to patients and loved ones, checking in to verify understanding. Reviewed patient history to verify conditions and current medications. Documented patient vitals, behaviors and conditions to communicate concerns to supervisor . LVN 01/2014 to 02/2018

Manos De Oro

Performed chart audits/quality assurance chart checks in a high volume office setting as per CMS/Medicaid guidelines.

Gave strong attention to detail and maintained good analytical skills. Self-directed with astute judgment skills. High level of personal accountability. Applied nursing expertise to meet needs of Every patients in challenging environment. Educated family members and caregivers on patient care instructions. Collaborated with physicians to quickly assess patients and deliver appropriate treatment while managing rapidly changing conditions.

Managed patients recovering from medical or surgical procedures, including facilitating wound care, ostomy care, pressure ulcer prevention and pain management. LVN 02/2018 to 03/2021

Genuine Home Health

Performed chart audits/quality assurance on nurses notes and physician orders to be in compliance with Medicare/Medicaid guidelines.

Answered phones, performed other clerical office duties as needed. Reviewed patient history to verify conditions and current medications. Responded to patient requests with appropriate clinical and personal assistance. Delivered oral medications, intramuscular injections and IV fluids to mitigate or resolve patient symptoms.

Provided basic patient care and treatment, such as administering tests, taking temperature and blood pressure and dressing wounds.

Assessed patients' temperature, pulse and blood pressure and recorded in electronic medical records.

Performed duties in accordance with all applicable standards, policies and regulatory guidelines to promote safe working environment.

LVN Vaccine Coordinator 04/2021 to 08/2021

Loyal Source Government Services, LLC

Performed chart audits, chart reviews for completion and accuracy. Reviewed charts to ensure all necessary documents, orders, referrals, labs, medical information is accurately captured.

Reviewed charts to ensure referrals were appropriately documented and delivered to referral department.

Noted any special healthcare needs and communicated needs with leadership team, quality assurance nurse for reporting purposes.

Entered medical health assessment encounters into UAC Portal and Vision Link. Reviewed records to ensure labs, referrals, vaccines are documented in both systems appropriately.

Reviewed UAC record and identified if any vital signs were WNL or out of parameters. If vital signs were out of parameters, I addressed with provider and nurse immediately to ensure medical interventions were taken and documented accordingly in record. Ensured follow up notes are documented in UAC Portal Ensured any ordered medications by provider were transcribed correctly onto MAR. Performed other miscellaneous office duties as needed. Performed physical assessments and gave medications and treatments as per provider orders. Took samples to complete diagnostic and routine assessment tests. Cared for wounds, provided treatments and assisted with procedures. Assistance Vaccine Coordinator/Vaccine administration Instructor. Gave immunizations at clinic.

Proficient with Microsoft office products and knowledgeable with operating the following systems such as Vision Link, UAC Portal, Point Click Care, AXXESS, HCHB, and IMMTRAC. Entered vaccine information via IMMTRAC as per state guidelines. LVN 08/2021 to 12/2021

Krucial Staffing

Performed chart audits to each individual patient record to be in compliance with ORR guidelines.

Entered medical health assessment encounters into UC Portal and Vision Link. Ensured each UAC vaccinated record was entered via IMMTRAC. Ensured ordered medications were transcribed correctly onto MAR. Ensured all follow up notes are documented in UC Portal, and performed any other miscellaneous duties in office as needed.

Assessed patients' temperature, pulse and blood pressure and recorded in electronic medical records.

Cared for wounds, provided treatments and assisted with procedures. Worked with unaccompanied children.

Responsible for vaccination of children and young adults. LVN 01/2022 to 03/2022

Angel Staffing

Responded to patient requests with appropriate clinical and personal assistance. Documented patient vitals, behaviors and conditions to communicate concerns to supervising nurse.

Managed patient care through closely monitoring respiration, blood pressure and blood glucose levels.

Monitored, tracked and conveyed important patient information to healthcare staff to help optimize treatment planning and care delivery.

Performed routine evaluations of each patient's status, needs and preferences. Obtained patient vital signs and input/output measurements from inpatients. Comforted and counseled patients and families throughout care process. Administered injectable and oral medications to psychiatric patients. LVN Chart Auditor 06/2022 to 12/2022

Loyal Source Government Services, LLC – Pecos, TX

Assessed patients' temperature, pulse and blood pressure and recorded in electronic medical records.

Documented patient vitals, behaviors and conditions to communicate concerns to supervising Job title.

Responded to patient requests with appropriate clinical and personal assistance. Worked with multidisciplinary team to carry out successful treatment plans for diverse acute and chronic conditions.

Input data into computer programs and filing systems. Maintained accuracy, completeness and security for medical records and health information. Reviewed medical records for completeness and filed records in alphabetic and numeric order.

Communicated effectively with staff, patients and insurance companies by email and telephone.

Maintained database for storage and retrieval of medical records. Followed exact procedures for handling transfers and other releases of medical records. Secured medical records against loss or unauthorized access. Compiled electronic patient records covering conditions, treatments and diagnoses. Processed patient admission and discharge documentation. Created new physical and computer-based files.

Prepared and processed forms for government healthcare programs. Handled high-volume data entry of demographics, disease etiology and extent and associated procedures or treatments.

Education

LVN License: NURSING 2005

Coastal Bend College - Alice, TX

I attended Coastal Bend College

Continuing education in Nursing

Coursework in Hospice, Palliative Nursing and Gerontology Emphasis in Occupational Health

GED 01/1997

Alice High School - Alice, TX

Skills

Wound Care

Transcribing Orders

Oral Conditions

Multi-Tasking and Prioritization

Intramuscular Injections

Medication Side Effect Knowledge

Collecting Vitals

Counting Narcotics

Indirect Patient Care

Writing Reports

Reading Comprehension

Assisting Physicians

Pressure Wound Treatment

Vital Sign Monitoring

Care Planning

Breathing Treatments

HIPAA Protocols

Nursing Process

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