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Recovery Audit and Appeal Denials (RAAD) Nurse Analyst Reviewer Resume Example

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RECOVERY AUDIT AND APPEAL DENIALS (RAAD) NURSE ANALYST REVIEWER
Executive Profile

Ambitious certified clinical documentation specialist with passion for creating strategic alliances with key stake holders across multiple facilities to effectively align with and support key business initiatives related to clinical documentation. High performing and committed to exceeding quality and productivity standards and the use of accurate and meaningful data to measure program performance. Experience in third party coordinated as well as independent CDI program implementation as well as shared leadership, oversight and responsibility of a system wide CDI program. Adept in policy/procedure development, team building, performance and quality improvement while exhibiting professionalism and integrity in a variety of work settings.

Skill Highlights

  • Innovative problem solving and ability to act decisively
  • Identifying risks, gap analysis, action planning
  • Managing multiple priorities CMS, Oryxx, OIG, PEPPER analysis
  • ICD-9 and ICD-10 coding and documentation compliance
  • Word, Quickbase, Risk Assessment, Six Sigma, Root Cause Analysis, JCAHO, patient safety indicators, HIPPA, data abstraction, analysis and reporting, PI/QI
  • Recovery Audit and Appeal Denials management and prevention for commercial insurance providers, Medicaid, and Medicare
  • Time and Resource Optimization
  • Analytical Skills
  • Departmental Operations Management
  • Knowledge of HMOs, Medicare and Medicaid
  • Claims analysis and review specialist
  • Staffing management ability
  • Regulatory compliance
  • Quality assessment of coded data
  • CPT and HCPCS coding
Core Accomplishments

Operations Management: 

  • Managed [operation].
  • Handled all functions related to [program].

Staff Development: 

  • Launched well-received program of professional development courses for all staff.
  • Mentored and coached employees resulting in a 12% increase in productivity.

Professional Experience
Company NameCity, StateRecovery Audit and Appeal Denials (RAAD) Nurse Analyst Reviewer06/2015
Company NameCity, StateClinical Documentation Specialist05/2013 to 06/2015
  • Transitioned from frontline CDS role into CDI analyst/educator and program liaison for Ministry Saint Josephs, Saint Clares, and Saint Michael's Hospitals Septemeber 2013.
  • Oversight, facilitation, developement of ICD10 CDI physician education team efforts.
  • Involved with Provident Consulting Group in ICD10 readiness pertaining to CDI and physician education for the entire Ministry market.
  • Developed standardized CDI physician orientation materials, ensured integration within physician onboarding process.
  • Planned, organized, supervised, provided assignments for SCH, SJH, and SMH with department size ranging from 2 to 9 employees with 100% case review of new patient admissions Advisory resource for CDI program and coding department to determine coding compliance and clinical validation as an adjunct process for RAC/RAAD denials and the CDI internal quality assurance.
  • Created CDI/coding database application with accurate tracking of case review determinations, findings and data analysis capabilities.
  • Expanded the CDI department's QA (Quality Assurance) process improving performance and maintaining high standards of compliant clinical documentation and improvement.
  • Developed internal auditing process and action plans increasing accountability and improving DRG impact related diagnosis capture.
  • Established and maintains positive relationships with coding department leaders, physicians and other key internal and external stakeholders throughout the system CDI program.
  • Plans, coordinates, organizes and directs efforts involving ICD10 physician and CDI education.
  • Serves as liaison between CDI director and frontline CDI staff as well as coding department leadership and associates Successfully planned, coordinated, organized and supervised implementation of CDI program in 2 Eastern Region hospitals.
Company NameCity, StateQuality Improvement Specialist Core Measures Coordinator12/2010 to 05/2013
  • Maintained up-to-date knowledge of TJC standards, WI state standards, CMS standards, as well as any other applicable regulatory agencies.
  • Facilitated operational teams in examining existing clinical and operational processes, and made recommendations for improvement through WHA, IHI, and internal QI initiatives (Partners for Patients, JOINTS program).
  • Medical Staff Peer review process development and involvement.
  • Reviewed compliance with regulatory requirements, practice standards, and medical staff approved expectations.
  • Provided ongoing reports to administration, leadership, and medical staff as requested.
  • Expert in concurrent and retrospective data abstraction methods and processes Provided training, mentoring, and ongoing support to personnel performing data abstraction.
  • Conducted audits of data and applied principles of inter-rater reliability methodology.
  • Submitted data and/or reports, on behalf of the organization, to regulatory agencies.
  • Interacted and communicated accurately, consistently, and appropriately with both internal and external customers.
  • Applied continuous quality improvement principles and methodology successfully to improve CMS Core Measure Compliance metrics.
  • Facilitated multi-disciplinary team meetings to improve processes and patient care (Cardiovascular Surgery QI team, Sepsis Morbidity and Mortality meeting).
  • Assisted as ad hoc member of risk management program to minimize the hospitals potential for liability.
  • Reviewed incident/near miss events as well as incident reporting process for trends requiring intervention.
  • Participated in multidisciplinary process improvement teams for the root cause analysis or sentinel event investigations.
  • Ensured that appropriate incidents are sent to regulatory or accrediting agencies.
  • Coordinated clinical quality programs and timely submission of data to regulatory and accrediting programs.
  • Ensured accuracy of data submitted.
  • Knowledge in accreditation and regulatory requirements including state and federal regulation as well as JCAHO and Wisconsin State Medical Society.
  • Provided analysis of clinical quality data to identify opportunities to improve patient safety and care.
  • Revised policies and procedures in accordance with changes in local, state and federal laws and regulations.
Company NameCity, StateQuality Improvement Specialist07/2009 to 12/2010
  • Clinical Documentation Improvement.
  • Implemented and coordinated the Clinical Documentation Management Program (CDMP).
  • Identified clinical documentation opportunities to more accurately reflect the severity of illness in DRG assignment.
  • Provided education to physicians, health care providers, and coding associates in terms of the documentation required by CMS to accurately capture severity of illness and meet coding guidelines in DRG assignment.
  • Performed clinical chart review audit for compliance and coding standards as well as proper use, full utilization, documentation and optimization.
  • Achieved departmental goals and objectives by instituting new processes and standards for clinical documentation improvement.
  • Carefully reviewed medical records for accuracy and completion as required by insurance companies.
  • Examined diagnosis codes for accuracy, completeness, specificity and appropriateness according to services rendered.
  • Consistently ensured proper coding, sequencing of diagnoses and procedures.
  • Demonstrated knowledge of HIPAA Privacy and Security Regulations by appropriately handling patient information.
Company NameCity, StateSurgical Clinical Nurse Reviewer08/2006 to 05/2009
  • Implemented and coordinated the National Surgical Quality Improvement Program (NSQIP) for general and vascular surgery at SJH from its inception.
  • Collected clinical data on variables, including preoperative risk factors, intraoperative variables and 30-day postoperative mortality and morbidity outcomes for patients undergoing major and minor surgical procedures in both inpatient and outpatient settings.
  • Data abstraction and submission with interrater reliability > 95% Analyzed data and outcomes through application of statistical methodology to identify opportunities for QI projects and to improve patient care.
  • Participated in monthly General and Vascular Surgery Morbidity and Mortality conferences.
  • Identified, developed and provided leadership for a LSSM greenbelt project and committee derived from NSQIP data analysis.
  • Participated in the development of a suicide inpatient risk assessment tool to meet 2007 JCAHO requirements.
  • Provided education and ongoing support to improve the accuracy in assigning wound classification in the OR to ensure accuracy as it pertains to reliability as a predictor variable for surgical site infection Presented NSQIP semi-annual report data to key stakeholders including hospital administration, surgeons, and OR staff.
  • Co-chaired and developed the NSQIP General Surgery Committee.
  • Incorporated SCIP measures into ongoing NSQIP data analysis to determine if SCIP outliers developed post-op complications.
Company NameCity, StateClinical Documentation Improvement Specialist11/2003 to 08/2006
  • Implemented and coordinated the Clinical Documentation Management Program (CDMP) from its inception in 2003 at St Joseph's Hospital.
  • Identified clinical documentation opportunities to more accurately reflect the severity of illness in DRG assignment.
  • Extensive education to physicians, health care providers, and coding staff in terms of the documentation required by CMS to accurately capture severity of illness and meet coding guidelines in DRG assignment.
  • Clinical chart review audit for compliance and coding standards as well as proper use, full utilization, documentation and optimization.
  • Achieved departmental goals and objectives by instituting new processes and standards for clinical documentation improvement Carefully reviewed medical records for accuracy and completion as required by insurance companies.
  • Examined diagnosis codes for accuracy, completeness, specificity and appropriateness according to services rendered.
  • Consistently ensured proper coding, sequencing of diagnoses and procedures.
  • Demonstrated knowledge of HIPAA Privacy and Security Regulations by appropriately handling patient information.
Education
Bachelor of Science:NursingUniversity of Wisconsin, City, StateNursing
University of Wisconsin Eau Claire, City, State
Health SystemsUniversity of Wisconsin Green Bay, City, StateHealth Systems Sept 2015 with projected graduation summer of 2017
Skills
ad, analyst, CMS, compliance reporting, conferences, Conflict resolution, Consulting, data analysis, data analysis, database, diagnosis, Documentation, educator, ICD10, ICD-10, ICD-9, insurance, internal auditing, leadership, director, Managing, market, materials, meetings, mentoring, PowerPoint, Microsoft Word, optimization, patient care, patient safety, Peer review, personnel, policies, problem solving, process development, processes, improve processes, process improvement, program development, coding, quality, quality assurance, Quality Improvement, QA, reporting, Risk Assessment, risk management, Six Sigma, Surgery, validation
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Resume Overview

School Attended

  • University of Wisconsin
  • University of Wisconsin Eau Claire
  • University of Wisconsin Green Bay

Job Titles Held:

  • Recovery Audit and Appeal Denials (RAAD) Nurse Analyst Reviewer
  • Clinical Documentation Specialist
  • Quality Improvement Specialist Core Measures Coordinator
  • Quality Improvement Specialist
  • Surgical Clinical Nurse Reviewer
  • Clinical Documentation Improvement Specialist

Degrees

  • Bachelor of Science : Nursing
    Health Systems