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work at home hedis clinical review specialist contract resume example with 17+ years of experience

Jessica
Claire
resumesample@example.com
(555) 432-1000,
Montgomery Street, San Francisco, CA 94105
:
Professional Summary
Highly energetic and motivational Nurse with more than 30 years clinical experience in Geriatrics, Pediatrics, Mental Health, Medical Surgical, and Orthopedic Nursing.  Manage Care experience includes MDS Resident Assessment Instrument for Long Term Care and Medicare and Medicaid Reimbursement Systems. CPT/ICD-9/10 Billing and Coding for Prospective Payment systems. Extensive  experience as a Quality Clinical review with CARA Risk Adjustment, HEDIS Advantage, and Medicare Claims Integrity Projects. 
Licenses
Licensed Practical Nurse
Skill Highlights
  • Knowledge of Medicare and Medicaid regulations
  • Strong clinical judgement
  • Independent judgement and decision making
  • ICD 9/10 inpatient and outpatient coding
  • Seasoned in Medical clinical procedures
  • Quality assessment of coded data
  • Adept at prioritizing and managing deadlines
  • Experienced patient chart auditing
  • Medical terminology expert
  • Through knowledge of private and commercial insurance carriers
  • HIPAA compliance
Education and Training
State University New York, Expected in 1989 Bachelor of Arts : Counseling - GPA : Counseling
, Expected in Coursework in Community Mental Health : - GPA :
Buffalo Vocational Technical Center Buffalo, NY Expected in 1982 : - GPA : Received Florence Nightengale Excellence in Nursing Care Award
Professional Experience
Catholic Charities Of The Archidiocese Of Washington - Work at Home Hedis Clinical Review Specialist (Contract)
Silver Spring, MD, 01/2016 - 04/2016
Applied structured auditing criteria to medical records to determine compliance with standards of the External Accountability Set (EAS) performance measures; and accurately enter the results of chart audits into a database.  Conducted medical record reviews by first identifying the eligible population and then extracting relevant data to serve as indicators for healthcare measures, to include body mass index assessments, colorectal and breast cancer screenings, managing diabetes and blood pressure issues, and other measures. Processed all abstracted information through record upload or data entry tool (DCT).   Ensured that HEDIS processes and outcomes complied with all applicable accreditation standards and regulatory requirements. Also provided clinical quality management and ad-hoc reporting as needed. 
Reagency HealthCare And Rehabilitation - LPN/Rehab Charge Nurse
City, STATE, 11/2015 - Current
Performed nursing techniques as prescribed for the comfort and well being of the Patient.  Administered medications orally, injection, sublingual, gastric tube, ect.  Observed resident's reactions to medication and treatments and documented findings. Assisted Physician with rounds; transcription of verbal, telephone, and written orders. Ensure proper handling and storage of medication and controlled substances. Planned, supervised, and instructed Certified Nursing Assistant's daily work assignments to ensure positive outcome of care provided to their patient's. Facilitated an on-going assessment of patient/family needs and implementation of interdisciplinary team care plan. Assessed need for, ordered, obtained and interpreted appropriate lab tests. Chronic patient care in med-surg unit, adeptly handling all aspects of treatment from medication to wound care.  Liaised between patients and physicians to ensure patient comprehension of treatment plans. Performed lab tests and communicated results. Closely monitored acute conditions. Followed infection control procedures and isolation procedures. Collected blood, tissue and other laboratory specimens and prepared them for lab testing.
Huntsville Health And Rehab - LPN/Rehab Charge Nurse
City, STATE, 01/2014 - 03/2015
Responsible for daily operations on Orthopedic / Medical - Surgical Rehabilitation Unit. Performed nursing techniques as prescribed for the comfort and well being of the Patient. Administered medications, orally, by injection, gastric tube, ect.  Observed resident's reactions to medication and treatments and documented findings. Assisted Physician with rounds; transcription of verbal, telephone, and written orders. Ensure proper handling and storage of medication and controlled substances. Planned, supervised, and instructed Certified Nursing Assistant's daily work assignments to ensure positive outcome of care provided to their patient's. Facilitated an on-going assessment of patient/family needs and implementation of interdisciplinary team care plan. Assessed need for, ordered, obtained and interpreted appropriate lab tests. Chronic patient care in med-surg unit, adeptly handling all aspects of treatment from medication to wound care.  Liaised between patients and physicians to ensure patient comprehension of treatment plans. Performed lab tests and communicated results. Closely monitored acute conditions. Followed infection control procedures. Collected blood, tissue and other laboratory specimens and prepared them for lab testing.
Redstone Health And Rehabilitation - Nurse Manager
City, STATE, 07/2013 - 2014
Resident Assessment Instrument for long term care for Medicare and Medicaid Reimbursement Systems, certification and Re-certification of Managed Care Residents. ICD-9 billing and coding for Prospective Payment Systems. Assessed Resident's needs and developed care plans so staff can insure that physical and clinical needs were met. Directed weekly care plan meetings with Interdisciplinary care plan team and family members to insure staff providing necessary care to loved ones. Coached and disciplined staff as need to ensuring nursing policies are being followed as set by State Of Alabama Nursing Home regulations.   Inserviced staff when new policies were set into place to improve Resident's physical and clinical needs. Transcription of physician orders Assisted in resolving and satisfying client requests and internal operational issues. Facilitated an on-going assessment of patient/family needs and implementation of interdisciplinary team care plan. Investigated and reported issues relating to patient care or conditions that might hinder patient well-being. Closely monitored acute conditions. Ensured HIPAA compliance. Coordinated Quality Improvement Activities (QIA's) to identify performance areas for improvement. Authorized drug refills and provided detailed prescription information to pharmacies. Followed infection control procedures. 
INOVALON, LLC - Remote Clinical Review Specialist
City, STATE, 09/2010 - 06/2013
  • Worked independently on several projects such as HEDIS Advantage, CARA Risk Adjustment, and Medicare Claims Integrity.
  • While working these projects I exceed departmental goals for productivity.
  • Followed State, Federal and NCQA guidelines while working these projects.
  • Consistently complied with applicable laws and regulations and ensured company adhered to Medicare and Medicaid regulations.
  • Continually maintained and improved the company's reputation and positive image in the markets served.
  • Reviewed customer survey information to prioritize areas of improvement.
  • Routinely collaborated with department managers to correct problems and improve services.
  • Confirmed accurate completion of forms/reports for the admission, transfer and/or discharge of each resident.
  • Ensured HIPAA compliance.
  • Researched CPT and ICD-9 coding discrepancies for compliance and reimbursement accuracy.
  • Accurately selected the proper descriptive code when more than one anatomical location was indicated.
  • Reviewed, analyzed and managed coding of diagnostic and treatment procedures contained in outpatient and inpatient medical records.
  • Maintained strict patient and physician confidentiality.
  • Actively maintained current working knowledge of CPT and ICD-9 coding principles, government regulation, protocols and third party requirements regarding billing.
  • Meticulously identified and rectified inconsistencies, deficiencies and discrepancies in medical documentation.
Windsor House Nursing And RehabilitationCenter - MDS Coordinator/Nurse Manager
City, STATE, 06/2006 - 09/2010
  • Resident Assessment Instrument for long term care for Medicare and Medicaid Reimbursement Systems, certification and Re-certification of Managed Care Residents.
  • ICD-9 billing and coding for Prospective Payment Systems.
  • Assessed Resident's needs and developed care plans so staff can insure that physical and clinical needs were met.
  • Directed weekly care plan meetings with Interdisplinary care plan team and family members to insure staff providing necessary care to loved ones.
  • Coached and discipline staff as need- ensuring nursing policies are being followed.
  • Provide inservice to staff when new policies were set into place to improve Resident's physical and clinical needs.
  • Transcription of physician orders Assisted in resolving and satisfying client requests and internal operational issues.
  • Facilitated an on-going assessment of patient/family needs and implementation of interdisciplinary team care plan.
  • Investigated and reported issues relating to patient care or conditions that might hinder patient well-being.
  • Closely monitored acute conditions.
  • Ensured HIPAA compliance.
  • Coordinated Quality Improvement Activities (QIA's) to identify performance areas for improvement.
  • Experience with various medical conditions including Parkinson's, Dementia, Diabetes, Cancer, Alzheimer's and Paget's disease.
  • Authorized drug refills and provided detailed prescription information to pharmacies.
  • Followed infection control procedures.
  • Ensured efficacy of treatments through monitoring of treatment regimens.
Center Of BuckHead - Medicare/ MDS Coordinator
City, STATE, 06/2005 - 05/2006
  • Resident Assessment Instrument for long term care for Medicare and Medicaid Reimbersement Systems, Pre-certification and Re-certification of Managed Care Residents.
  • ICD-9 billing and coding for Prospective Payment Systems.
  • Developed and implemented patient care plans, including assessments, evaluations and nursing diagnosis.
  • Directed weekly care plan meeting with Intersiplinary care plan team and family members to insure staff providing necessary care to loved ones.
  • Coached and discipline staff as need- ensuring nursing policies are being followed.
  • Provided in service to staff when new policies were set into place to improve Resident's physical and clinical needs.
  • Prepared equipment and assisted MD with their rounds.
  • Transcription of physician orders Reviewed customer survey information to prioritize areas of improvement.
  • Routinely collaborated with department managers to correct problems and improve services.
  • Chronic patient care in med-surg unit, adeptly handling all aspects of treatment from medication to wound care to monitoring for number patients per shift.
  • Oversaw and managed 50 plus clinical and support staff in patient care activities while maintaining a high level of staff morale and professionalism.
  • Coordinated Quality Improvement Activities (QIA's) to identify performance areas for improvement.
Big Spring'sSpeciality And Rehabilitation Cent - LPN/ Rehabilitation Charge Nurse
City, STATE, 11/2003 - 05/2005
  • Responsible for daily operations on Orthopedic / Medical - Surgical Rehabilitation Unit.
  • Performed nursing techniques as prescribed for the comfort and well being of the Patient.
  • Administered medications, orally, by injection, and or gastric tube.
  • Observed resident's reactions to medication and treatments and documented findings.
  • Assisted Physician with rounds; transcription of verbal, telephone, and written orders.
  • Ensure proper handling and storage of medication and controlled substances.
  • Planned, supervised, and instructed Certified Nursing Assistant's daily work assignments to ensure positive outcome of care provided to their patient's.
  • Facilitated an on-going assessment of patient/family needs and implementation of interdisciplinary team care plan.
  • Assessed need for, ordered, obtained and interpreted appropriate lab tests.
  • Chronic patient care in med-surg unit, adeptly handling all aspects of treatment from medication to wound care.
  • Liaised between patients and physicians to ensure patient comprehension of treatment plans.
  • Performed lab tests and communicated results.
  • Closely monitored acute conditions.
  • Followed infection control procedures.
  • Collected blood, tissue and other laboratory specimens and prepared them for lab testing.
Rehab And HealthCare Center - MDS and Restorative Rehabilitation Coordinator
City, STATE, 11/2002 - 10/2003
  • Resident Assessment Instrument for long term care for Medicare and Medicaid Reimbersement Systems, Pre-certification and Re-certification of Managed Care Residents.
  • ICD-9 billing and coding for Prospective Payment Systems.
  • Assessed Resident's needs and developed care plans so staff can insure that physical and clinical needs were met.
  • Directed weekly care plan meeting with Intersiplinary care plan team and family members to insure staff providing necessary care to loved ones.
  • Coached and discipline staff as need- ensuring nursing policies are being followed.
  • Provided inservice to staff when new policies were put into place to improve Resident's physical and clinical needs.
  • Prepared equipment and assissted with their rounds.
  • Transcription of physician orders Investigated and reported issues relating to patient care or conditions that might hinder patient well-being.
  • Certified that equipment and supplies were properly maintained for quality patient care and safety.
  • Assigned employee areas, scheduled staff breaks and authorized overtime.
Skills

Chart auditing, billing, cancer, decision making, Diabetes, diagnosis, documentation, forms, government, Hospice, ICD-9/10, infection control, insurance, lab testing, managing, Medical terminology, meetings, Mental Health, Neurology, Nursing, Patient Care, Patient evaluation, policies, coding, protocols, Quality Improvement, Rehabilitation, safety, Excellent computer skills, Transcription, treatment plans, wound care

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Resume Overview

School Attended

  • State University
  • Buffalo Vocational Technical Center

Job Titles Held:

  • Work at Home Hedis Clinical Review Specialist (Contract)
  • LPN/Rehab Charge Nurse
  • LPN/Rehab Charge Nurse
  • Nurse Manager
  • Remote Clinical Review Specialist
  • MDS Coordinator/Nurse Manager
  • Medicare/ MDS Coordinator
  • LPN/ Rehabilitation Charge Nurse
  • MDS and Restorative Rehabilitation Coordinator

Degrees

  • Bachelor of Arts
  • Coursework in Community Mental Health

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