Utilization Review Specialist Established, meticulous professional with over 30+ years’ experience leading utilization review (UR) and International Classification of Diseases (ICD) coding in healthcare environments. Proven ability to apply extensive expertise in UR analytical review, case management, ICD diagnosis related groups (DRG), as well as billing auditing and reporting to maximize operational efficiency across different hospitals. Collaborative leader with track record of partnering with internal and external teams and stakeholders to ensure synergy and align compliance goals. Communicative, adept at problem resolution, administrative support, and providing patient-centric care. Areas of expertise include: Business Operations Team Leadership and Development Process and Operational Improvement Geriatric Treatment Relationship Management DRG/ICD Coding Compliance Insurance Billing Inventory Management Planning and Coordination Driven Director with experience planning and coordinating all aspects of productions.
Skills
MS DRG Validation
Utilization review
Recruiting and hiring
Company guidelines
CMS Compliance Guidelines
Denials letters
Developed and implemented the annual UR compliance work plan for my team
Developed audit job description
Developed analytic report for audit purposes
Experience
07/2002 to 03/2020
Sr. Director UR/Coding/MS-DRG ComplianceHospital Sisters Health System - Corporate – Litchfield, IL,
Utilization and ICD Coding/DRG Compliance, Oversaw utilization review and MSDRG ICD coding management team schedule to ensure timely completion of compliance work and overall efficiency.
Reviewed and kept abreast of Medicare and Medicaid (CMS) policies and regulatory guidelines to ensure strict compliance across hospitals.
Collaborated closely with case managers and health information departments to track, monitor, and record compliance efforts and performance, while resolving telephonic and email queries regarding regulatory guidance.
Developed and implemented audit worksheets to support scope of work for acute inpatient, outpatient observation, ICD coding, and post-acute care including SNF, swing bed, inpatient rehab, home health and inpatient and psychiatric care.
Spearheaded annual compliance work plan.
Ensured health care financial compliance at all times.
Developed annual risk assessment and compliance department calendar for UR and ICD coding team.
Delivered hands-on assistance to committees and teams within department in policy-making decisions.
Established and oversaw yearly budgets for my team.
Reviewed completed work to verify consistency, quality and performance plans.
Collaborated with compliance directors and staff members to organize schedules by factoring in production requirements and materials availability.
Met or exceeded professional and personal goals every year by completing the work plan and professional growth {i.e InterQual trainer, CMS rules and MS-DRG/ICD coding.
Conducted quality evaluations of team performance and compliance policies to standardize activities.
Studied scripts to assess creative direction and resource requirements for successful compliance program.
07/2002 to 03/2011
Sr. Manager DRG/ICD Coding Compliance AuditorGreater Lawrence Family Health Center – Essex Street, MA,
Troubleshot and resolved problems with programs and systems.
Supported customers by answering questions and guiding end-use.
Tested newly installed programs and applications to validate operability.
Trained end-users in best practices to minimize errors and protect key data.
Integrated new technologies to meet area requirements.
Expanded systems with new features and structural components.
Reviewed and assessed networks to determine areas for improvement.
Coordinated and implemented network security measures to protect data.
Maximized information sharing by optimizing interface linking to different computer systems.
Documented phases of systems and software update and restoration projects.
Created reports detailing findings and recommendations.
Completed quality assurance reviews to assess accuracy of data and validate results.
Performed in-depth analysis to help solve diverse problems with program implementation and operations.
Utilized knowledge of data modeling and statistical analysis to note trends and draw conclusions.
Defined application problems by consulting with clients to evaluate procedures and processes.
Developed streamlined task system to provide more effective workflows for both peers and management staff.
Observed staff to study daily tasks regarding information processing and performance to better understand business system needs.
Assisted with improvements to operations by showing clear connection between current policies and business results.
10/2001 to 07/2002
Case ManagerFort Transfer – Dearborn Heights, MI,
Developed appropriate care plans for at-risk individuals and high-risk families.
Coordinated support services and optimized communication between healthcare workers and patients.
Informed patients and families of treatment options and at-home care strategies to reduce unnecessary burden on hospital resources.
Collaborated with various healthcare providers to facilitate delivery of services.
Coordinated resources from diverse providers for intervention plans.
Optimized program resource utilization to prevent unnecessary hospital admissions.
Communicated with legal services providers, social services agencies and local judicial systems regarding cases.
Used facility EMR system to update patient records, transmit prescriptions and transfer files.
Reviewed treatment plans against individual goals and healthcare standards.
Lowered costs while improving care quality by coordinating services and collaborating with dedicated healthcare team.
Facilitated ongoing case management services to support successful outcomes and meet stabilization goals.
Participated in case conferences with multi-disciplinary team to discuss client care planning and progression.
Cooperated with local service providers, outreach workers, case managers and collaborative agencies to facilitate services for members.
Developed comprehensive client-driven case plan with short and long-term goals.
Protected patient data in alignment with HIPAA privacy protocols.
Conducted assessments to obtain information for participant-centered plan of care.
Determined functional status, activity, acuity and self-management levels to make proper care referrals.
Performed audits of objectives and case progression for case management team.
Identified strengths and opportunities for staff improvement based on audit results.
07/2001 to 03/2002
Health Information Management DirectorArdent Health Services – Harker Heights, TX,
Worked with physicians and nurses to find methods to improve quality of patient health documents and records.
Took part in meetings and committees to discuss such topics as electronic health records and communicate best ways to improve workflows.
Put new coding and billing procedures into practice, which helped to reduce number of claims that insurance companies denied.
Interviewed and hired talented performers, bringing exemplary expertise and knowledge to job positions within organization.
Managed and directed 17 individuals within organization.
Developed data management plans and reports, validation procedures and data entry processes.
Managed user access, including activating and deactivating accounts, upholding strict security standards in all areas.
Worked successfully with diverse group of coworkers to accomplish goals and address issues related to our products and services.
Worked closely with team members to deliver project requirements, develop solutions and meet deadlines.
Prioritized and organized tasks to efficiently accomplish service goals.
Juggled multiple projects and tasks to ensure high quality and timely delivery.
07/1982 to 07/1988
RN Utilization Review and DRG/Coding CoordinatorAlabama Quality Assurance Foundation {AQAF} – City, STATE,
ICD 9 CM Coding, Utilization Review and MSDRG.
Audited and completed charts, evaluations and medical forms.
Reviewed and completed admission and discharge assessments.
Communicated with hospital DRG review for educat.
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ManagerMC Strategies – City, STATE,
Trained employees on additional job positions to maintain coverage of roles.
Assigned tasks to associates to fit skill levels and maximize team performance.
Recruited and hired qualified candidates to fill open positions.
Greeted and encouraged feedback from customers to implement in-store operational changes.
Conducted charge capture audits by assessing current state of department integrity against medical record accuracy levels and tracking variances.
Collaborated with staff to maximize customer satisfaction, streamline procedures and improve bottom-line profitability.
Established and created training programs to enhance employee knowledge of best practices, resulting in improved customer satisfaction.
Evaluated operational trends and proactively adjusted strategies to maintain alignment between performance and objectives.
Aided in negotiation with vendors and suppliers to reduce overall costs.
Delivered level of service to customers in effort to build upon relationships for future clients.
Upheld company's high standards for business via leading by example and encouraging team members to adhere to corporate policies.
Completed daily audit reports and analyzed metrics to identify trends.
Set challenging yet attainable goals to encourage continuous staff development.
MS-DRG/coding audits educating the hospital ICD coding staff.
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Charge NurseFlorence Hospital And Eliza Coffee Hospital – City, STATE,
Assessed and assisted patients with diverse range and comorbid chronic diagnoses, including chronic obstructive pulmonary disease (COPD), asthma, congestive heart failure (CHF), cerebrovascular accidents (CVA), diabetes, and sepsis.
Built and maintained strong working relationships between nursing department and other disciplines.
Coordinated and performed patient admissions, transfers and discharges.
Oversaw medication administration, monitored distribution and documented responses.
Educated patients, caregivers, and families on diagnoses, treatment and disease prevention.
Collaborated with multidisciplinary healthcare specialists to devise, implement, and modify plans of care defining patient outcome goals
Supported physicians and consultants with tests and procedures.
Audited patient charts in real-time, verifying accuracy and completion of information.
Organized and delegated tasks during rapid response and high-pressure code situations.
Distributed assignments to RNs, LPNs and resident advisors, guided work and delivered training to promote proper care standards for patients.
Assessed unit patients continuously from admission to discharge.
Trained and mentored new RNs on best practices, hospital policies and standards of care.
Performed IV infusions, intramuscular injections, peritoneal dialysis, IV pushes and oral subcutaneous.
Directed unit staff and promoted quality care for diverse patients.
Advised, coached and mentored experienced and student nurses on medical issues, crisis management and appropriate nursing interventions.
Implemented interventions and strategies to manage chest tubes, nasogastric tubes and G-tubes.
Coordinated, tasked and supervised nurses and ancillary staff based on staffing requirements.
Prioritized care and assessed needs through skilled triaging of incoming phone calls from ER and inpatient units.
Managed central lines, catheters and vascular access devices.
Conducted telemetry monitoring on patients, recording cardiac rhythm data.
Education and Training
Expected in
Associate of Science: Register Nursing Northwest Jr College - , AL GPA:
Expected in
: Life And Health Insurance University of Alabama - Birmingham, GPA:
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