Equipped with strong problem-solving abilities, willingness to learn, and excellent communication skills. Poised to contribute to team success and achieve positive results. Ready to tackle new challenges and advance organizational objectives with dedication and enthusiasm.
Work History
CDI
10 Years 8 Months
Randolph Health | 01.2016 - Current
review medical record to ensure accurate reflection of SOI and ROM,
review medical record assigns initial DRG
Validated documentation supports diagnosis with clinical indicators
issues physician queries concurrent and post discharge to clarify ambiguous, incomplete, or inconsistent clinical documentation and monitor for and address delinquent queries with physicians
work with coders to validate documentation and DRG
Maintain up to date on ICD 10 cm coding guidelines
assist with coders in ICD 10 Inpatient coding as needed
Administered medications and treatments as prescribed by healthcare professionals.
Monitored patient vital signs, reporting changes to medical team promptly.
Assisted in developing individualized care plans tailored to patient needs.
Educated patients and families on health management and wellness strategies.
Collaborated with interdisciplinary teams to optimize patient care outcomes.
Trained and mentored new nursing staff on protocols and procedures.
Implemented best practices for infection control and patient safety measures.
Improved patient outcomes by administering medications, monitoring vital signs, and documenting relevant information.
Evaluated patient progress, adjusting care plans based on ongoing assessments.
Cared for wounds, provided treatments, and assisted with procedures.
Assisted with admissions, appointments, transfers, and discharges.
Documented accurate and complete patient information to address patient problems and expected outcomes.
Demonstrated excellent technical skills in wound dressing changes, IV therapy administration, catheter insertion, and other routine nursing procedures.
Performed routine evaluations of each patient's status, needs, and preferences.
Adapted quickly to changing patient needs, adjusting care plans accordingly to ensure optimal outcomes in diverse clinical scenarios.
Administered controlled narcotics, inserted IVs, and performed catheterizations.
Comforted and counseled patients and families throughout care process.
Provided compassionate palliative care for terminally ill patients while supporting their emotional needs during end-of-life stages.