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
Professional Experience
01/2016 to 04/2016
Work at Home Hedis Clinical Review Specialist (Contract)Catholic Charities Of The Archidiocese Of Washington – Silver Spring, MD, 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.
11/2015 to Current
LPN/Rehab Charge NurseReagency HealthCare And Rehabilitation – City, STATE, 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.
01/2014 to 03/2015
LPN/Rehab Charge NurseHuntsville Health And Rehab – City, STATE,
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.
07/2013 to 2014
Nurse ManagerRedstone Health And Rehabilitation – City, STATE, 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.
09/2010 to 06/2013
Remote Clinical Review SpecialistINOVALON, LLC – City, STATE,
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.
06/2006 to 09/2010
MDS Coordinator/Nurse ManagerWindsor House Nursing And RehabilitationCenter – City, STATE,
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.
06/2005 to 05/2006
Medicare/ MDS CoordinatorCenter Of BuckHead – City, STATE,
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.
11/2003 to 05/2005
LPN/ Rehabilitation Charge NurseBig Spring'sSpeciality And Rehabilitation Cent – City, STATE,
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.
11/2002 to 10/2003
MDS and Restorative Rehabilitation CoordinatorRehab And HealthCare Center – City, STATE,
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.
Education and Training
Expected in 1989
Bachelor of Arts: Counseling State University - New York, GPA: Counseling
Expected in
Coursework in Community Mental Health: - , GPA:
Expected in 1982
: Buffalo Vocational Technical Center - Buffalo, NY GPA: Received Florence Nightengale Excellence in Nursing Care Award
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Work at Home Hedis Clinical Review Specialist (Contract)
