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Skills

  • Cost-saving initiatives in claims processing
  • Health Insurance Portability and Accountability Act (HIPAA) compliance
  • Claims approval rate optimization
  • High-cost procedure claims management
  • Medication administration
  • Insurance billing protocols
  • Chronic disease management
  • Women's health exams
  • ICD-9 forms
  • Trauma recovery

Work Experiences

  • Advocated for patients in my care and implemented prescribed treatment strategies using firsthand knowledge and clinical expertise.
  • Allowed for faster processing times.
  • Provided critical-ill patients with a skilled, timely, and level-headed emergency response.
  • Updated patient charts with data such as medications using Salesforce in order to keep records current and support accurate treatments.
  • Analyzed complex claim denials for accuracy, leading to a 66% improvement in approval rates after implementing corrective measures.
  • Addressed pending claims queries.
  • Achieved Innovation Award for best departmental results.
  • Conducted ongoing assessments to assess mental health needs and collaborated with a multidisciplinary team to create, implement, manage, and modify individualized care plans.
  • Assisted in the development of workflow automation tools.
  • Provided patient education and answered questions about their health, prognosis, and treatment options.

Summaries

  • Achieved a 18% reduction in manual intervention.
  • Dedicated, hardworking, and experienced process Registered Nurse with experience in patient care, medication monitoring, and treatment management.
  • With expert healthcare knowledge, clear verbal and written communication skills, and sound clinical judgment, this person is team-oriented and dependable.
  • Recognized on a regular basis for outstanding performance and contributions to the Miscellaneous industry's success.
  • Pended Claims Review Nurse with a passion for health screenings and treating patients with program and procedure diseases.
  • With strong attention to detail, clinical expertise, and emergency response experience, she is adaptable and resilient.
  • Proven track record of using critical thinking, analysis, and medical knowledge to provide exceptional care in high-pressure situations.
  • Achieved this in 6 months.
  • Recognized for motivating management team members to achieve their goals and fostering innovative work environments.
  • Action-oriented professional.

Accomplishments

  • Resolved product issue through consumer testing.
  • Applied clinical guidelines to ensure appropriate reimbursements for high-cost medical diagnosis, preventing overpayments totaling $10.
  • Collaboratively worked with clinical staff to ensure accurate documentation for medical necessity, reducing claim denials by 78%.
  • Reduced litigation risk by properly documenting and negotiating settlements on complex claims valued at more than $6.
  • Analyzed data from claim management software to notify leadership of emerging trends, reducing future claim denials by 20%.
  • Led a cross-functional team to implement a system-wide transition to a new claims management software, reducing manual claim handling time by 79% hours per claim.
  • Utilized claims systems effectively to reduce pending high-risk claims by 61%, significantly improving throughput for the team.
  • Utilized extensive expertise in ICD-10 and CPT codes to accurately review 2 claims per week, expediting the payment process.
  • Achieved President's Club for consistently being in the top 71% of the team in resolving pended claims within allocated timeframes.
  • Delivered consistent performance by surpassing KPIs, including reducing claim review error rates to 27% over 3-month period.

Affiliations

  • Association for Clinical Documentation Improvement Specialists (ACDIS)
  • American Society of Safety Professionals
  • Jaycees
  • Toastmasters
  • American College of Healthcare Executives (ACHE)
  • Society for Healthcare Risk Management (SHRM)
  • Rotary International
  • National Association of Insurance Commissioners (NAIC)
  • Managed Care Nurses Certification (MCN)
  • American Medical Informatics Association

Certifications

  • First Aid/CPR Certified
  • Certified Public Accountant
  • Certified Public Accountant (CPA)
  • Certified Business Analysis Professional (CBAP)
  • Healthcare Risk Management Certification (CPHRM)
  • Certified in Healthcare Compliance (CHC)
  • Commission for Case Manager Certification (CCMC)
  • Certified Professional in Healthcare Quality (CPHQ)
  • AHIMA Certified Coding Specialist (CCS)
  • Certified Case Manager (CCM)

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