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Clinical Reviewer/Clinical Compliance Auditor Resume Example

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CLINICAL REVIEWER/CLINICAL COMPLIANCE AUDITOR
Professional Summary
Responsible Licensed Practical Nurse with excellent communication skills demonstrated by 5 years of experience in healthcare. Enthusiastic and excellent people skills and dedicated work ethic. Demonstrated medical procedure competency.
Work History
Clinical Reviewer/Clinical Compliance Auditor, 07/2015 to Current
EviCore Healthcare – Bluffton, SC
  • Performed over 300 compliance audits per month for Healthfirst.
  • Analyzed all audit results and resolved all compliance issues.
  • Trained new employees on how to perform a compliance audit and educated them on NCQA, URAC, CMS and state regulations. 
  • Assisted with complaints from the ordering provider.
Clinical Reviewer/Clinical Appeals Nurse, 04/2010
eviCore Healthcare – Bluffton, SC
  • Obtained Clinical information from nurses and doctors regarding patient history, medication, family history and lab and test results to provide prior authorizations for patients for test such as MRI, CTs, MRAs, and VQ scans.
  • Worked with 20 plus healthcare plans which affected more than 30 million lives.
  • Worked with patients and doctor offices through the appeal process, informed them of the guidelines for each health plan and worked with them to get the test approved.
  • Gained proficient computer and customer service skills.
Floor Nurse, 05/2009 to 03/2010
Cape Fear Valley Health System – Fayetteville, NC
  • Chronic patient care in med-surg unit, adeptly handling all aspects of treatment from medication (IV, oral, and subcutaneous medications)to wound care to monitoring for 4-6 patients per shift.
  • Admitted and discharged patients which included patient education on various topics such as new diagnoses and medications.
  • Oriented new nurses to the floor and was responsible for student nurses.
  • Worked closely with doctors to inform them of any changes in the patients condition, which included taking orders and implementing those orders.
  • Charted daily and made notes regarding the patients day to day activities.
Wound Care Nurse, 05/2008 to 04/2009
Effingham Health Systems – GA
  • Responsible for over 100 residents, reviewed daily skin assessments, bandaged and applied medications to various wounds such as bed sores, surgical scars, and care of GI tubes and colostomy bags.
  • Weekly charting and meetings with supervisors to inform them of the progress of the wounds and the patients general well-being.
  • Worked as a PRN floor nurse and was responsible for assessments of patients, administering oral medications and monitoring tube feedings.
Skills
  • Strong clinical judgment
  • High level of autonomy
  • Patient/family focused
  • Problem resolution capability
  • Thorough physical assessments
  • Patient and family advocacy
Education
Diploma: Licensed Practical Nurse, 2008
Savannah Technical College - Savannah, Ga
Obtained my CNA license and Patient Care Technician certificate
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Resume Overview

Companies Worked For:

  • EviCore Healthcare
  • eviCore Healthcare
  • Cape Fear Valley Health System
  • Effingham Health Systems

School Attended

  • Savannah Technical College

Job Titles Held:

  • Clinical Reviewer/Clinical Compliance Auditor
  • Clinical Reviewer/Clinical Appeals Nurse
  • Floor Nurse
  • Wound Care Nurse

Degrees

  • Diploma : Licensed Practical Nurse , 2008

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