Quality Performance & HEDIS Nurse Specialist

ROBIN E. GONZALES, RN

Glenville, New York 518-***-**** *************@*****.***

PROFESSIONAL PROFILE

Registered Nurse, CRC with 2 years of CDI experience, 33 years of bedside nursing experience and 10 years of medical records (HEDIS, CDI, Risk Adjustment) experience

Clinical Documentation Integrity Specialist with a passion for medical record management and quality improvement initiatives.

Unique experiential background in medical records, quality improvement, cardiovascular/cardiac nursing and nursing education.

Consistent record of attaining high-quality ratings in a fast-paced, deadline-driven work environment.

Clinical Documentation Review Specialist with exemplary results in meeting deadlines and accuracy

PROFESSIONAL CREDENTIALS / AFFILIATIONS

Registered Nurse – State of New York (Current thru 7/2027)

Registered Nurse – State of Arizona (Inactive)

Certified Risk Adjustment Coder AAPC, 2022 (expired)

EDUCATION

B.S. in Nursing – Arizona State University, Tempe, Arizona

CCRN Certification – expired

AAPC CPC-A Certification CPC 2011 (not renewed)

AAPC Certification CRC – June 2022 (not renewed)

MEDICAL RECORDS / DOCUMENTATION EXPERIENCE

The Judge Group (Contract)

Elevance Health – Indianapolis, IN

HEDIS Research, Abstraction – October 2024 – May 2025

National Committee for Quality Assurance retrospective review of services and performance of care for Measurement Year 2024

Responsible for reviewing records of discharged patients for completeness and accuracy of provider documentation for assigned hospital.

Demonstrates understanding of Measurement categories and ability to locate appropriate information during chart review.

Demonstrates accurate data entry into database tool.

Demonstrates competency in use of programs used in data collection and data entry: QSHR, Member360, Facets, Reveleer, Sharepoint, and Microsoft Teams.

One of 5 seasonal staff asked to start early (Oct vs January) and to stay later than majority of seasonal staff to do “deep dives” looking for last minute compliant data from reviewed records.

The Judge Group (Contract)

Elevance Health – Indianapolis, IN

HEDIS Research, Abstraction – December 2023 – April 2024

National Committee for Quality Assurance retrospective review of services and performance of care for Measurement Year 2023

Responsible for reviewing records of discharged patients in measurement year for completeness and accuracy of provider documentation for assigned hospital.

Demonstrates competency in knowledge related to HEDIS – measures and required data needed to meet specifications set by NCQA.

Demonstrates competency in use of programs used for data collection and data entry: Member360, Facets, Sharepoint, and Microsoft Teams, Microsoft Word, Excel. Cotivity Quality Reporter (QR Web and Cotivity Reporter).

Demonstrates confidence in ability to work independently as well as a member of a team

Demonstrates ability to serve as a resource to members of a team related to equipment, software/Apps and everyday activities necessary to function on a daily basis.

The Judge Group (Contract)

Elevance Health – Indianapolis, IN

HEDIS Research, Abstraction – January 2023 – April 2023

National Committee for Quality Assurance retrospective review of services and performance of care for Measurement Year 2022.

Responsible for reviewing records of discharged patients for completeness and accuracy of provider documentation for assigned hospital.

Demonstrates understanding of Measurement categories and ability to locate appropriate information during chart review.

Demonstrates accurate data entry into database tool.

Demonstrates competency in use of programs used in data collection and data entry: QSHR, Member360, Facets, Reveleer, Sharepoint, and Microsoft Teams.

AMN Healthcare (Contract) – San Diego, CA

Advent Health – Tampa, Florida

Remote Clinical Documentation Specialist – September 2022 – November 2022

Responsible for reviewing records of discharged patients for completeness and accuracy of provider documentation for assigned hospital.

Correctly identifies physician clarification opportunities

Proficient in formulating valid clarifications that are easily understood by physicians and other members of the medical team.

Accurately reconciles all cases in CDI database.

Communicates closely with HIM coders to resolve discrepancies in DRG assignments and other coding issues.

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Adobe Care and Wellness – Tempe, Arizona

Remote Clinical Documentation Review Specialist, Risk Adjustment– October 2020 – June 2021

Remote position

Detailed review of outpatient medical records of Medicare members in preparation for in-home/telehealth visits from Nurse Practitioners.

•Collaborated extensively with in-home assessment nurse practitioners to improve the quality and completeness of documentation by doing prospective record reviews to identify appropriate diagnoses based on CMS HCC categories.

•Following CMS guidelines, uses Hierarchical Condition Coding to ensure appropriate capture and documentation of HCC codes in order to positively impact the health care of our members.

•Communicates with and educates all clinical staff concerning accurate and effective clinical documentation. Interact with peers in a collegial manner, supporting efforts to improve outcomes.

•Ensures quality, effectiveness, and efficiency in case review activities.

•Skilled in reading/reviewing medical documents such as surgical reports, in-patient medical records, and diagnostic reports to ensure correct diagnosis code assignment.

•Facilitates and obtains appropriate clinical medical record documentation on a concurrent basis to support appropriate/expected severity of illness/risk of mortality, complexity of care, medical necessity, and appropriate reimbursement for treatment and services provided.

•Works collaboratively with physicians, other healthcare professionals and coding staff to ensure that clinical information in the medical record is present and accurate so that the appropriate utilization, clinical severity, outcomes and quality is captured for the level of service rendered to all patients, as well as ensuring compliant reimbursement of patient care services.

•With 3 part time staff and 2 RN’s over 900 back-logged record reviews, in addition to daily influx of records, were completed between mid-October 2020 and end of January 2021 (ahead of schedule).

•Works daily to improve knowledge base related to HCC coding and appropriate documentation practices.

•Attends and participates in interdisciplinary group meetings.

•Compliance with HIPAA regulations

St. Peter’s Hospital – Albany, New York

Clinical Documentation Integrity Specialist – July 2018 – June 2020

•Proficient in reviewing, assigning and validating ICD-10-CM codes for diagnoses performed by physicians and other qualified healthcare providers.

•Skilled in reading/reviewing medical documents such as surgical reports, in-patient medical records, and diagnostic reports to ensure correct diagnosis code assignment.

•Facilitates and obtains appropriate clinical medical record documentation on a concurrent basis to support appropriate/expected severity of illness/risk of mortality, complexity of care, medical necessity, and appropriate reimbursement for treatment and services provided.

•Works collaboratively with physicians, other healthcare professionals and coding staff to ensure that clinical information in the medical record is present and accurate so that the appropriate utilization, clinical severity, outcomes and quality is captured for the level of service rendered to all patients, as well as ensuring compliant reimbursement of patient care services.

BlueShield of Northeastern New York / HealthNow New York, Albany and Buffalo, New York

Healthcare Quality Improvement Specialist – August 2011 – January 2018

•Collected and analyzed medical records for a variety of medical initiatives in accordance with local, state and federal regulatory requirements.

•Collaborated with the Buffalo office to procure/scrutinize 5,000+ medical records across New York state for multiple large-scale projects; prenatal record project resulted in a deficiency-free audit.

•Coordinated and completed HEDIS Department quality improvement activities that were consistent with organizational strategy, commitments and goals.

•Conducted multiple clinical quality audits and identified potential areas for quality improvement.

•Assisted in hiring up to eight temporary staff for the HEDIS audit season; trained staff on the purpose and methodologies in collecting medical records data, as well as verified data reliability.

•Worked with physician practices to implement and identify opportunities to optimize HEDIS encounter data; enlisted support to effectuate change and incorporate best practice solutions.

•Teamed with others in the development of a documentation tool for collecting data from prenatal through postpartum periods, based on the New York State Medicaid Prenatal Care Standards.

•Achieved, as part of a team, an overall quality rating of 4.0 – 4.5 (out of 5.0) from the Centers of Medicare and Medicaid Services for six consecutive years.

•Traveled across Upstate New York for purposes of reviewing patient EHR’s utilizing multiple different electronic medical record systems

BlueShield of Northeastern New York (Fusco Personnel), Albany, New York

Medical Claims Processor, Temporary Assignment – March 2011 – August 2011

•Reviewed and processed new insurance claims to determine if the patient’s procedure was medically necessary, and if the specific policy covered the procedure.

•Fielded calls from patients, doctors and hospitals to answer questions, address concerns and provide updates regarding the status of the claim.

•Remitted payment to doctors and hospitals based on valid claims; sent letters to doctors, hospitals and patients when the claim was denied communicating reasons for decision.

NURSING EXPERIENCE

Glens Falls Hospital, Glens Falls, New York

Staff Nurse, Cardiovascular / Cardiac Catheterization – April 2003 – July 2010

•Provided quality care to patients from hospital admissions through discharge; monitored patient’s vital signs, administered medications and provided treatment as necessary.

•Conducted phone interviews to obtain pre-admission information for patients requiring treatment in the cardiovascular intervention department.

•Assisted physicians with the performance of cardiac catheterizations, angioplasties, pacemaker implantations and battery changes, transesophageal echocardiograms for diagnostic purposes.

•Served as the primary on-call nurse caring for patients admitted to the emergency room with myocardial infarction.

•Delivered instructions and education to patients and their families, prior to discharge, including information on medications, nutrition and care of the surgical site.

Ellis Hospital, Schenectady, New York

Nurse Educator – August 2001 – February 2003

•Teamed with medical providers, patient care staff and unit managers in the planning, implementation and delivery of educational curricula.

•Collaborated with the critical nurse educator in providing education and competency reviews for critical care staff.

•Served as the primary educator for the pediatric and adult psychiatric departments.

•Facilitated opportunities for pharmaceutical representatives to provide instruction to staff on department-specific medications.

•Ensured proper care in the use and maintenance of equipment, supplies and instruments to guarantee high levels of workplace safety and environmental practices.

•Initiated clinical skill development programs within parameters of established clinical and preceptorship models; monitored trends and implemented strategies to ensure compliance.

•Provided education to telemetry staff related to EKG readings and interpretation.

•Was an Advanced Cardiac Life Support Instructor

St. Luke’s Medical Center, Phoenix, Arizona

Staff Nurse/Charge Nurse in Critical Care Unit (SCU Special Care Unit and Nurse Manager Inpatient Geriatric Psychiatry Unit – January 1979 – October 2000

•Staff nurse/Charge nurse 20 bed Critical Care Unit treating all patients needing intensive nursing care – open heart, vascular surgery, pulmonary, poisonings, orthopedic, general surgical patients

•Critical Care education team lead with responsibility of setting up and assisting with yearly staff education and competency reviews for critical care staff.

•Instructor for all hospital staff (RN, LPN, PCT/CNA/MD) computer training for first “Go Live” with EHR (Cerner) in 1999 – 2000

•Nurse Manager for inpatient locked Geropsychiatry unit

Phoenix General Hospital, Phoenix, Arizona – January 1977– January 1979

Staff RN in ICU/CCU; Night shift charge nurse step down unit with telemetry

TECHNICAL SKILLS

• ICD-10 (International Classification of Disease Systems)

• HCPro Clinical Documentation Improvement Boot Camp 6/2020

• Facets (Claims Program)

• HIXNY (Remote Record Access Program)

• 3M™ 360 Encompass™ System/Computer Assisted CDI Program

• Cerner Electronic Health Record (order processing function)

• Athena Electronic Health Record

• MEDENT Electronic Health Record

• Allscripts Electronic Health Record

• e-Clinical Electronic Health Record

• QSHR

• Member360

• Reveleer

• Sharepoint

LICENSURE and AFFILIATIONS

New York State (Office of the Professions) - RN Nursing license (current) thru 7/2027

Arizona State Board of Nursing – RN (current)

AAPC (American Academy of Professional Coders) - current 2022- 2023(expired)

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