Documentation Specialist Development

EDUCATION: Loyola University, New Orleans, LA

**** ****** ** ******* ** Nursing, Health Care Systems Mgmt.

Texas Woman’s University, Denton, TX

**** ******** ** ******* ** Nursing

Dallas County Community College. Dallas, TX

2002 Nursing Prerequisites

CERTIFICATIONS: ELNEC Trainer

Clinical Documentation Improvement Educator-Outpatient

Heuristic Analysis Certificate

Certified Clinical Documentation Specialist--Outpatient

EXPERIENCE:

08/2022 to Present: (full time)

Ortho Colorado, Littleton, CO,

Clinical Nurse Leader: responsible for improving the quality of patient care using evidence-based practice.

Duties Include:

•Coordinating patient care from start to finish

•Measuring patient outcomes

•Overseeing patient transitions of care

•Assessing risks and researching

•Implementing new internal policies

•Building communication channels between teams

09/2020 to 06/2022: Veterans Admin. Audie L. Murphy VAMC; San Antonio, TX

Clinical Documentation Improvement Educator (full time): Responsible for the clinical documentation improvement educator for Community Based Outpatient Clinics (CBOC), Medical Service and Primary Care.

Duties include:

•review of patient charts for proper use of the Evaluation and Management Tool,

•Capturing of Hierarchical Care Categories (HCC) based on chart reviews,

•Accurately assess risk of mortality and severity of illness and Risk Adjustment Factor (RAF) score

•Provide education to providers on requirements for capturing and documenting co-morbid conditions.

•Responsibilities included all Community Based Outpatient Clinics, Medical, and Primary Care.

•Detailed to med/surg units, patient load 7 acute care, COVID patients, and pre/post op.

•Detailed to telemedicine to monitor COVID patients at home.

06/2020 to 09/2020 (full time)

Veterans Admin. Northwest Health Care System, Roseburg, OR (Full time) Simulation Coordinator: Responsible for the Coordination of Education and Simulation Training for Nursing and Medical Staff.

Duties Included:

•Establish policies and procedures for Clinical Lab and Simulation Department

•Collaborate with National and Regional Simulation Centers to develop and implement high quality learning and assessment experiences

•Collaborate with Nurse Managers and Medical Staff to promote learning, critical thinking, and clinical reasoning skills.

•Coordinate with Nursing /Medical staff to ensure learning needs are met.

•Coordinate Lab and Simulation Center schedule to maximize student learning.

•Program simulators to model patient physiological responses during simulation exercises.

•Support and assist in role-playing applications, prop placement, and moulage set -up for lab and simulation experiences.

•Operate simulators and audio/visual equipment for Clinical Simulation Center Users.

•Provide recommendations for budget and purchase of equipment, supplies, and materials related to the Clinical and Lab Simulation Center.

•Coordinate maintenance of patient simulators, part-task trainers, and Clinical Simulation Center audio-visual equipment and other lab equipment.

•Coordinate preparation of human patient simulators, part-task trainers, programmed patients, simulation rooms, and other equipment /props for faculty conducting lab and simulation experiments.

•Coordinate purchase of supplies needed to operate the Clinical Lab and Simulation Center.

09/2019 to 06/2020: Christus Santa Rosa Westover Hills, San Antonio, TX (full time).

Throughput RN: Responsible for the admission and follow through to discharge of patients’ length of stay.

Duties Included:

•Working with the Medical Teams to initiate the plan of care for patients and the approximate day of discharge.

•Working directly with the case managers and direct care nursing staff preparing the patient for discharge so all orders are carried out, allowing the patient to discharge within the time limit as set by the admitting DRG GLOS.

•Working directly with the case managers anticipating the needs of the patient before discharge.

•Working with providers and the completion of orders so patients can be discharged before 0900 and 1100.

•Scheduling the medical transportation for patients that will be transferring to SNF or LTAC, ensuring that unnecessary delays for discharge are avoided.

03/2019 to 07/2019 Baptist Medical Center, San Antonio, Tx (Full-Time).

Admission /Discharge RN: Responsible for the admission and discharges of patient on the medical surgical units.

Duties Included:

•Carried a patient load of 7, providing direct care as a bedside nurse.

•Responsible for assessments, medications, admission, and discharges.

06/15 to 11/18 Veterans Admin. North Texas Health Care System, Dallas, TX (Full time—retired in 11/2018)

Clinical Documentation Improvement Specialist—Registered Nurse Program Manager: Responsible and accountable for oversight of all elements of the Clinical Documentation Improvement program for the North Texas VAMC.

Duties Included:

•Utilize knowledge of Diagnosis Related Group and Third-party payment regulations.

•Accountable for utilizing collaborative strategies with physicians’ mid-level providers, other members of the interdisciplinary team, Health Information Management (HIM) staff to ensure the severity of illness and level of service provided are accurately reflected in the medical record, maximizing third party and Veterans Equitable Resource Allocation collections.

•Provides on-going education regarding documentation requirements and International Classification of Disease Coding.

•Performs data validation of code assignment specific to type of care provided.

•Maintains current clinical knowledge to efficiently review medical records.

•Perform documentation audits and identifies opportunities for improvement.

•Generated an increase in revenue 15% from previous years in first six-months of program initiation.

•Advanced VHA-North Texas from a One-Star facility to a Three-Star facility within first nine months of program implementation.

•Increased the Severity of Illness, Risk of Mortality from 0.8 in previous years to 1.2 in first nine months of program implementation.

Staff Development Specialist: For Specialty Clinics, Occupational Health, Tricare, Bed Control, Physical Medicine & Rehabilitation, Non-Veteran Care Coordinators.

Duties Included:

•Provide leadership in the application of the nursing process to patient care, organizational processes, and systems to improve outcomes for clients and staff.

•Developed the Memorandum, designed the curriculum, and composed core competencies for the Intravenous Therapy course for the Licensed Vocational Nurses

•Involved in the Kaizen for Cycle Time of Credentialing and Privileging

•Involved in the Kaizen for Coordination of Care at Discharge

•Redesigned and distributed nursing competencies to better complement the teaching provided by nurse educators on recent evidence- based practice

•Developed and distributed the Core Competency for Nurses assigned to Physical Medicine and Rehabilitation, Tricare, and Occupational Health Units

•Developed and implement educational plans to meet changing concepts of client care and technological advances, plan and participate in system wide educational programs for staff and clients

07/14 to 04/15 Cordova Community Medical Center, Cordova, AK (Full time)

Director of Nursing: At a critical access hospital in remote Alaska, including Emergency, Acute, Rehabilitation, and Long-Term Care.

Duties Included:

•Provided leadership to assure compliance with local, federal rules and regulations, and State of Alaska Nurse Practice Boards

•Analyzed processes and procedures, then designed new performance improvement initiatives to exceed resident admissions to the Long- Term Care Facility. This re-design generated over $100,000.00 in the first month for swing beds, with the estimated revenue of 1.2 million in 12 months

•Prepared staff for Annual State and Federal survey for Long Term Care, Acute Care, Emergency Care, and directed Senior Management in process improvement initiatives which reduced F-tags by 89% and Immediate Jeopardies by 100% from the previous fiscal year survey

•Lead, direct, and monitor the delivery of health care and related medical services and develop Quality Assurance Process Improvement action strategies

•Provided direct supervision to nursing staff including hiring permanent staff and maintaining a constant progression of traveling staff to meet the needs of the medical center to provide safe, efficient, and cost- effective care to clients

•Planned effective and efficient budget management that assured the best utilization of resources in a remote facility

•Developed and implemented health care related training to improve the care of clients and provide education to staff by utilizing relevant theorists to identify, analyze and trend data to resolve problem areas.

09/12 to 07/14 James H. Quillen, VAMC, Mountain Home, TN (Full time)

Hospice Palliative Care Coordinator:

Duties Included:

•Coordination of multiple disciplines involved in caring for patients at the end of life with the Palliative Care Consult Team, Acute Care Providers, Primary Care Providers, other healthcare professionals and team members. Collaborate with clinics, internal and external services and community agencies and the James H. Quillen VAMC Leadership team.

•Responsible for the development and implementation of End-of-Life education to all employees.

•Reviewed data in VSSC, prepared and presented reports to Executive Team reporting specific measures to monitor the effectiveness of the programs.

Utilize VSSC to compare data from previous years to track current year gains and develop action/improvement plans to improve scores within the VISN and Nationally.

•Designed and distributed the Hospice and Palliative Care Memorandum ensuring the document in compliance with regulatory standards and Veterans Health Administration directive.

•Designed and implemented No Veteran Dies Alone Program for the Mountain Home Veteran’s Administration Medical Center. Thirty volunteers were trained on end-of life issues unique to veterans and to “be a presence” to an actively dying Veteran.

•Coordinated with local hospice agencies in East Tennessee and collaborated with them in earning their stars as part of the We Honor Veterans initiative. Twenty- six agencies responded and five achieved a Level One partnership; two received a Level Two partnership, two received a Level Three partnership and two received a Level Four partnership.

•Developed a booklet for nursing staff and medical staff on end of life care.

•Attended new hospital orientation and provided education to all staff on Hospice/Palliative care.

•Attended resident luncheon and provided education on the diagnosis and related signs and symptoms needed to initiate a Hospice /Palliative consult.

•Utilized data from the SAIL report to identify Veterans at risk of utilizing palliative or possible hospice care within 12 months.

03/12 to 10/12 Raleigh General Hospital, Beckley, WV (Full time)

Staff Nurse, Medical –Surgical Unit

03/11 to 12/11 Baylor University Medical Center Corporate Offices, Dallas, TX Analyst, Implementation Services, Clinical Health Records, Baylor Information Services.

Duties Included:

•Responsible for the design, build and implementation of Hospice, Palliative Care, Pastoral Care and Oncology electronic health record.

•Participated in implementation and design by establishing methodology and templates to guide,

•design and complete workflow design documentation, generate design specs according to established standards, testing new build, and participating in integrated testing with application teams, and facilitated council approval for the new build and redesign.

•Completing SSC and crosswalks, workflow impact analysis, new build requirements, order set requirements and 1:1 with individuals and groups throughout the implementation to facilitate understanding and adoption of new workflows, build, procedures, roles, and use of tools.

•Change management and readiness work at each activation site, and collaboration with optimization team for smooth transition to post live support after activation is complete.

2007-2011 VA North Texas Health Care System, Dallas, TX (Full time)

Staff Development Specialist for Long Term Care, Rehab, Hospice and New Employee Orientation. (2009-2011)

Duties Included:

•Provided education in new employee orientation on Vista, CPRS, and BCMA. Assisted the new employees with maneuvering through the system until they were comfortable.

•Provided one on one computer training for new employees as needed.

•Responsible for the implementation and oversight in the day to day operation s of new employee orientation.

•Core Trainer for End of Life Nursing Education Consortium (ELNEC).

•Provided education based on the development of standards of professional practice, as required by the accrediting bodies and applicable regulations.

•Initiated quality improvement activities to collect data for analysis and made recommendations for change of practice based on evidence- based research.

•Participated on the Policy and Procedure Committee to update policies and assure compliance of VHA directives, Joint Commission Standards, and OIG requirements.

•Acting Nurse Manager for Medical/Surgical/Oncology Unit. Duties included implementation of shared governance; provide leadership in the application of the nursing process to patient - care. Manage daily operations and coordinate activities,

•Participate in quality improvement activities such as Falls Committee, Policy and Procedure Committee, participating in RCA’s, and guide other staff by assessing their performance based on applicable patient care standards. 2007-2009

•Main charge nurse on a 34 bed Medical/Surgical Unit. Duties included assessment of patients’ acuity, staffing, bed control, mentoring, acting as a coach and preceptor to staff and students.

2006-2007 Baylor University Medical Center, Dallas, TX (Full time)

Registered Nurse

•Staff nurse on a 37 bed Liver/Kidney/ Pancreas Transplant, and Gastric Bypass Unit.

•Duties performed: preparing patients for transplant surgery pre-operatively.

•Care of Post-Op patients including monitoring and administering of medications, including insulin drips, thymoglobulin, and anti-rejection medications.

2003-2006 VA North Texas Health Care System, Dallas, TX (Full time) Student Nurse Extern and Registered Nurse

Duties Included:

•Perform the duties of Charge Nurse on a continuous basis and

Team Leader on a 22 bed Pulmonary/ Respiratory /Medical /Surgical Unit.

•Make staff assignments reflecting optimum use of staff available and prioritize care needs of clients.

•Deliver care for complex client situations, acting as a resource person to other staff.

•Assess situations to determine client needs, goals and make the appropriate arrangements and referrals to provide achievement of client care goals,

•Function as a preceptor to new nurses and student nurses/

•Perform 24- hour chart audits, utilizing computer charting and medication administration via palm pilot device daily.

•Act as a client advocate when client’s self-determination abilities are in question.

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