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Skills

  • Sanitation
  • Insulin medication assistance
  • Care plan development
  • Trauma recovery
  • ICD-9 forms
  • Healthcare policy adherence
  • Case management
  • Case management across care settings
  • Patient safety protocols
  • Patient and family advocacy

Work Experiences

  • Updated patient charts with data such as medications using Power BI in order to keep records current and support accurate treatments.
  • Adjusted workflows.
  • Applied clinical judgment for decision-making.
  • Prepared blood, tissue, and other laboratory specimens for testing in the lab.
  • Assessed appropriateness of hospitalization.
  • Followed strict safety precautions by calculating the correct dosages before administering medications.
  • Analyzed trends in claim denials and created action plans, leading to $14 in recovered reimbursements within 2022.
  • Maintained quality standards by conducting routine medication audits and adhering to internal and industry best practices.
  • Analyzed trends in review outcomes.
  • Acted quickly in situations that threatened the unit's safety and security, implementing crisis prevention interventions to control and de-escalate the situation.

Summaries

  • Dedicated to learning, growing, and succeeding in Miscellaneous.
  • Accomplished Medical Review Nurse.
  • Medical Review Nurse is a multi-talented Medical Review Nurse who is consistently rewarded for planning and operational improvements.
  • Adept at providing expert clinical insight to support timely claims resolution and effective appeals processing, improving the resolution rate by 85%.
  • Accomplished in complex claim reviews, providing critical insights on claims over $8, and reducing inappropriate payments by leveraging evidence-based guidelines.
  • Registered Nurse, Oregon Board-Certified, with 12 years of experience providing high-quality care to patients in framework and standard care units.
  • A dedicated healthcare professional with a focus on utilizing evidence-based clinical guidelines and risk management strategies to expedite the claims process, reducing wait times by 10 hours.
  • Accomplished Medical Review Nurse proficient in chart review, medical documentation, and identifying documentation discrepancies, leading to a 51% decrease in medical billing errors.
  • Proven track record of using critical thinking, analysis, and medical knowledge to provide exceptional care in high-pressure situations.
  • Strengths in team leadership and data analysis backed up by Miscellaneous training.

Accomplishments

  • Produced data reports based on claims analysis, assisting in executive decision-making and reducing overall claim costs by 10 in three years.
  • Regularly communicated updates regarding regulatory changes and their impact on daily workflows, enhancing staff preparedness.
  • Successfully led monthly audit meetings, reducing denied claims by 57% within 2020 through data trend analysis.
  • Documented and resolved metric which led to system.
  • Collaborated with case managers to develop individualized patient care plans, reducing unnecessary treatments and costs.
  • Led a team in developing standardized medical review protocols, reducing claim resolution time by 17 days on average.
  • Monitored the latest updates in federal health insurance reforms and incorporated changes, improving compliance by 65%.
  • Identified process improvements in care team communication leading to 54% faster approval for time-sensitive treatments.
  • Worked closely with compliance officers to update review practices for current state and federal regulations, ensuring adherence with Lean.
  • Accurately assessed patient charts to verify appropriate billing codes were applied, preventing an estimated loss of 8 in revenue.

Affiliations

  • American Medical Informatics Association
  • Freemason
  • American Association of Managed Care Nurses (AAMCN)
  • Participant in the Clinical Denial Management Program hosted by Beacon Labs since 2018
  • Healthcare Financial Management Association (HFMA)
  • Active participant in regulatory audits through Northwind to ensure category
  • American Society of Safety Professionals
  • National Association of Social Workers
  • Certified Nurse Life Care Planner (CNLCP) through procedure, in good standing
  • Association for Supply Chain Management (APICS)

Certifications

  • Cisco Certified Network Associate (CCNA)
  • Current Registered Nurse License (RN) – Seattle
  • Google Certified Professional Cloud Architect
  • Certified Health Data Analyst (CHDA) - Vantage
  • Quality Improvement Associate Certification - Summit Group
  • CompTIA A+ Technician
  • Apple Certified Associate (ACA)
  • Salesforce
  • Project Management Professional (PMP)
  • Certified Clinical Documentation Specialist (CCDS) - Northwind

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