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Senior Provider Education Consultant Resume Example

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SENIOR PROVIDER EDUCATION CONSULTANT
Professional Summary
Thirty years of healthcare experience in nursing, managed healthcare and healthcare Fraud, Waste and Abuse that utilizes my many years of experience and specialized training.
Licenses
Licensed Practical Nurse in the State of MN, License number L
​
Professional Experience
Senior Provider Education Consultant04/2007 to 08/2016Company Name
  • Researched and authored "Provider Education" letters written to healthcare providers to educate them on documentation requirements of medical records, correct CPT/HCPCS coding and billing practices and general strategies and timelines for future improvement.
  • Act as a healthcare provider consultant to our internal legal department and external attorneys related to fraudulent providers.
  • Act as lead for the Provider Education Team's escalated issues resulting from letter follow-up questions or dispute of review findings post-appeal.
  • Investigate clinical cases submitted from the Department of Insurance (DOI) and Centers for Medicare/Medicaid Services (CMS) complaints as final resolution.
Business Analyst01/2005 to 02/2007Company NameCity, State
Assistant Manager02/1990 to 12/2004
  • Bill Review/Claims Operations, Health Risk Management (HRM) Negotiated hospital bill for cost-reduction after clinical review of the bills (UB92's).
  • Hired 30 new employees for a new start-up department called "Claims Operations" within a 60-day window.
  • Nursing- Licences and.
Senior Clinical Investigator
  • Escalation and Resolution Team, Optum Performed clinical reviews for highly escalated provider cases Determined if system flags placed to stop claims for potential fraud were effective and fair and whether or not system flags should be removed or added Performed as internal liaison to our internal legal team by building medical case histories and acting as clinical specialist by participating in legal conference calls or off-site meetings Clinical Investigator, Clinical Team, Optum (FKA Ingenix) Performed clinical reviews for all lines of business (private, commercial and government) Investigated top 10 fraudulent physicians for quarterly client reporting.
Education and Training
LPN in the State of MN, License #L28413-0Brooklyn Park Community College
Licensed from December 1987 through present Registered Nurse (RN), University of MN1980
Associate Degree: Interior DesignCentury CollegeInterior Design
Certified CoderJune 2006
Skills
billing, CMS, consultant, cost-reduction, CPT, client, documentation, government, Insurance, legal, letters, meetings, window, Nursing, coding, reporting, Risk Management, written
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Resume Overview

School Attended

  • Brooklyn Park Community College
  • Century College

Job Titles Held:

  • Senior Provider Education Consultant
  • Business Analyst
  • Assistant Manager
  • Senior Clinical Investigator

Degrees

  • LPN in the State of MN, License #L28413-0
    Licensed from December 1987 through present Registered Nurse (RN), University of MN 1980
    Associate Degree : Interior Design
    Certified Coder June 2006

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