Registered Nurse with over 20 years experience. Experience in Cotiviti and Claim Check editing for medical claims payment for the past nine years. Maintaining Certified Professional Coder credentials yearly. Recently acquired Nursing Informatics certification. Accomplished at identifying Cotiviti edits and clinical review to determine payment appropriateness on the QNXT platform. Most current experience is in reviewing plan exception requests and working with the UM steering committee and heath plans to review and follow policy to enact these exception requests. I also have experience in medical policy imp0lementation and Propat use. Organized, decisive, and attentive to details. Eager to contribute to team success. Excited to showcase abilities in the Healthcare QM Project Program Manager position.
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- Work with Cotiviti editing system daily to review claims for medical payment and correct coding.
- Work with Claim Check editing system daily to review claims for medical payment and correct coding.
- Consistently meet established Quality Assurance guidelines as well as production metrics for Claim Review Production
- Served as resource for Health Plan to explore and explain editing questions and issues with Cotiviti and Claim Check edits.
- Served as mentor for new staff and resource for other staff members
- Displayed functional familiarity with Medicare, commercial and private insurance coverage protocols.
- Followed all personal and health data procedures to effectively comply with HIPAA laws and prevent information breaches.
- Impacted successful patient outcomes by prioritizing safe and cost efficient discharge planning
- Collaborated with healthcare team members to plan, implement and enhance treatment plan and goals
- Used first-hand knowledge and clinical expertise to advocate for patients under review when making discharge planning arrangements
- Managed over 40 customer calls per day in Precertification role
- Supervised, directed and motivated high-quality performance from nursing staff.
- Trained new nurses in proper techniques, care standards, operational procedures and safety protocols to optimize performance and safety.
- Reviewed department performance and adjusted coverage to compensate for changing conditions.
- Advised caregivers and family members in providing emotional and psychological care to support patient needs.
- Established and continuously optimized unit schedules and individual work assignments.
- Delivered medications via oral, IV and intramuscular injections, monitoring responses to address new concerns.
- Actively engaged and participated in consults, patient care plan development and patient monitoring.
- Managed 15 nurses in long term care unit handling needs of residents with sever to profound mental retardation.
- Assessed patients to determine individual needs and develop care plans in coordination with multidisciplinary healthcare professionals
- Evaluated skills of all nursing personnel and verified staff certifications for validity.
- Conferred with physicians to discuss diagnoses and devise well-coordinated treatment approaches and advise of patient condition
- Implemented interventions, including medication and IV administration, catheter insertion and airway management.
- Audited charts and reviewed clinical documents to verify accuracy.
- Managed care for post-operative patients from initial recovery through discharge.
- Provided direct patient care, stabilized patients and determined next course of action.
- Documented patient information obtained from interviews concerning symptoms, medications and prior treatment.
- Facilitated therapeutic communication, conflict resolution and crisis intervention by redirecting negative behaviors and helping patients regain or improve coping abilities to prevent further disability.
- Delivered medications via oral, IV and intramuscular injections, monitoring responses to address new concerns.
- Managed patients recovering from medical or surgical procedures, including facilitating wound care, ostomy care, pressure ulcer prevention and pain management.
- Performed ongoing assessments to evaluate mental health needs, working with multidisciplinary team to develop, initiate, manage and modify individualized plans of care.
State of Pennsylvania- Registered Nurse, RN515068L
Certified Professional Coder
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School Attended
- Pennsylvania State University
- Slippery Rock University Of Pennsylvania
- Geisinger Medical Center School Of Nursing
Job Titles Held:
- Quality Management Nurse Consultant
- Precertification Nurse, Concurrent Review Nurse
- Assistant Nursing Supervisor
- Registered Nurse
Degrees
- Nursing Informatics Certificate
- Bachelor of Science
- Diploma
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