Medical Proofreader/ Editor/ Data Entry/ Administration | Clinical Documentation Integrity Specialist (CDIS - RN)

Rate, USD
Not specified
Work schedule
Contract, Full Time, Part Time,
Language skills
English
Available for Hire
Yes
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About me

I am a Registered Nurse (BSN) with over 30 years of clinical practice experience across various specialties including Labor & Delivery, Obstetrics, Operating Room, Cardiovascular OR and ICU, community nursing, geriatric nursing, and school nursing. Throughout my career, I have gained extensive expertise in medical transcription, editing, and EMR documentation. I am meticulous, HIPAA-compliant, and deadline-driven, with a strong focus on accuracy and quality in clinical documentation.

I specialize in medical proofreading, editing, transcription quality assurance, chart abstraction, and clinical documentation review. I have a keen eye for detail and am skilled in ensuring clarity, consistency, and compliance with style and format standards. My experience includes working with neurology and oncology reports, as well as authoring care plans and risk reports in clinical settings.

I am proficient in EMR/EHR systems and have strong technical skills including Microsoft Word, Excel, Outlook, WordPerfect, and secure messaging platforms. I am comfortable managing high-volume tasks while maintaining strict confidentiality and zero PHI breaches.

I am seeking fully remote, task-based roles in proofreading, editing, documentation quality assurance, or EHR/chart abstraction. While I prefer full-time employment, I am open to contract or part-time opportunities. I am available for day shifts and weekends, with a preference for every other Sunday off.

Currently, I am focused on medical recovery and online upskilling for coding and Clinical Documentation Integrity Specialist roles. I am eager to leverage my clinical and documentation expertise in a remote work environment to contribute to quality healthcare documentation and compliance.


Professional area



Education

1982/1987 Bachelor of Science in Nursing @ West Virginia University
2003/2004 Associate of Applied Science in Medical Office @ ECPI Technical College

National Technical Honor Society

2019/2021 Nurse Paralegal Certificate @ Brighton College

Experience

2008–2010 Proofreader/Editor @ Chesterfield Observer

Proofread news content for clarity, consistency, and accuracy; enforced style/format standards. Flagged clinical inconsistencies and missing data; improved readability and reduced errors.

2012–2013 Proofreader/Editor @ The Daily Sun

Proofread news content for clarity, consistency, and accuracy; enforced style/format standards. Flagged clinical inconsistencies and missing data; improved readability and reduced errors.

2004–2008 Medical Transcription/Editing @ Associated Neurologists

Transcribed/edited neurology reports with 99%+ accuracy; standardized terminology. Performed QA on dictated notes; ensured HIPAA compliance and on-time turnaround.

2011–2013 Medical Transcription/Editing @ US Oncology

Transcribed/edited oncology reports with 99%+ accuracy; standardized terminology. Performed QA on dictated notes; ensured HIPAA compliance and on-time turnaround.

2019–2020 Medical Transcription/Editing @ Lynn Dalbeck MT Services

Transcribed/edited medical reports, general medicine, with 99%+ accuracy; standardized terminology. Performed QA on dictated notes; ensured HIPAA compliance and on-time turnaround.

2023–2024 RN @ VITAS Hospice

• Provided home-based hospice care to terminally ill patients.
• Gained firsthand insight into end-of-life care; respectfully transitioned out of hospice work after initial experience.
Authored care plans, risk reports, and quarterly/annual summaries with precise EMR documentation. Abstracted key data to support quality metrics and audits; collaborated with interdisciplinary teams. Managed high-volume tasks with zero PHI breaches.

2020–2021 RN @ Sumter County Health Deptartment

•Worked with a team of four nurses in COVID-19 testing and vaccination efforts. Worked with populations in schools, jails, businesses, and senior facilities.
• Administered up to 400 vaccinations/day and tested 50–100 individuals/day.
Authored care plans, risk reports, and quarterly/annual summaries with precise EMR documentation. Abstracted key data to support quality metrics and audits; collaborated with interdisciplinary teams. Managed high-volume tasks with zero PHI breaches.

2014–2019 RN @ Agency for Persons with Disabilities, Tacachale

• Delivered daily care to up to 40 intellectually and developmentally disabled adults.
• Managed medications, diabetes care, wound treatment, and gastrostomy tubes.
• Served as primary nurse for 1–2 homes (13–15 residents each).
• Authored care plans, quarterly/annual reports, and risk management documentation.
• Collaborated with interdisciplinary teams including physicians, therapists, and dietitians.
Authored care plans, risk reports, and quarterly/annual summaries with precise EMR documentation. Abstracted key data to support quality metrics and audits; collaborated with interdisciplinary teams. Managed high-volume tasks with zero PHI breaches.


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