Dedicated registered nurse with over twenty years experience in a variety of health care settings seeking transition into clinical care management position
Iowa Registered Nurse License since 1993.
Analyzed commercial insurance and Medicare inpatient hospital claims to determine medical necessity for inpatient versus outpatient billing criteria. Participated in special projects for inpatient rehabilitation and outpatient therapies which required medical necessity review for skilled services criteria. Utilized Clinical review judgment to determine outcomes, occasionally utilized Milliman Guidelines to assist with findings outcomes. Maintained a greater than 98% accuracy for claim determinations
Performed home health care medical record reviews per Medicare pre-payment policies. Examined documentation for appropriate services were being provided while meeting regulatory standards required by Medicare. Researched Medicare regulations as needed.
Analyzed medical records for a wide variety of provider types for regulatory compliance with the Iowa Administrative Code and Code of Federal Regulations. Collaborated with the Iowa Medicaid Fraud Control Unit and the Iowa Attorney General's office. Presented cases before Iowa Administrative Law Judges. Assisted in exceeding yearly contract requirement of $20 million dollars to reach final amount of $23 million dollars.
Performed program integrity reviews for multiple provider types in accordance to the Iowa Administrative Code and Code of Federal Regulations. Examined claims for aberrant billing practices. Collaborated with the Iowa Medicaid Fraud Control Unit and the Iowa Attorney General's Office. Presented fifty cases before Iowa Administrative Judges with a win- loss record of 47 wins and only 3 losses. Participated in the preceptor process for new reviewers. Created training materials and binder for all reviewers to utilize during the review process. Total amount personally recoupmented was $1 million dollars.
Course work in medical-surgical nursing.
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