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Skills

  • Acute care expertise
  • Claims Denial Management
  • Data entry
  • Well visit procedures
  • Medical Claims Analysis
  • Insurance billing protocols
  • Case management
  • EMR / EHR
  • Electronic Health Record (EHR) integration
  • Trauma recovery

Work Experiences

  • Provided excellent care to patients with a variety of diagnoses and oversaw their treatment from start to finish.
  • Administered various therapies and medications in accordance with physician orders and treatment plans.
  • Led a successful 16-person team of registered nurses, licensed practical nurses, and ancillary staff.
  • Analyzed appeals for previously denied claims, achieving a 63% overturn rate, resulting in $2 recovered for payers.
  • Awarded Excellence Award for outstanding performance, consistently exceeding monthly review targets by 26% over three years.
  • Acted quickly in situations that threatened the unit's safety and security, implementing crisis prevention interventions to control and de-escalate the situation.
  • Analyzed key performance indicators (KPI) for the claims review team.
  • Achieved a 28% overturn rate.
  • Analyzed complex claim denials for accuracy, leading to a 66% improvement in approval rates after implementing corrective measures.
  • Averted potential litigation costs of $10.

Summaries

  • Adaptable claims review expert actively staying current with the latest healthcare policies and regulations to ensure fewer compliance issues and maintain review accuracy.
  • Dedicated, hardworking, and experienced process Registered Nurse with experience in patient care, medication monitoring, and treatment management.
  • Considered to be a hard worker with a strong desire to succeed.
  • Recognized on a regular basis for outstanding performance and contributions to the Miscellaneous industry's success.
  • Costs were consistently reduced while profits were increased.
  • Action-oriented professional with significant contributions to workflow automation efforts, decreasing manual intervention in claims processing by 82%.
  • Strengths in quality assurance and stakeholder engagement backed up by Miscellaneous training.
  • Registered Nurse, Washington Board-Certified, with 10 years of experience providing high-quality care to patients in system and process care units.
  • Achieved results over 6 months.
  • Dedicated to learning, growing, and succeeding in Miscellaneous.

Accomplishments

  • Utilized extensive expertise in ICD-10 and CPT codes to accurately review 2 claims per week, expediting the payment process.
  • Resolved complex medical claims involving diagnostic codes for high-cost treatments, leading to an organizational savings of $14.
  • Reengineered the claims validation workflow, decreasing manual effort by 26% while ensuring consistent accuracy in reviews.
  • Proactively identified patterns in denied claim submissions, leading to an improvement in claims accuracy and increasing approval rates by 51%.
  • Earned Six Sigma to better align with industry standards and regulatory requirements, resulting in improved claim adjudication accuracy.
  • Collaborated with team of 11 in the development of metric.
  • Provided expert training on the Claims Management System (CMS) to newly onboarded team members, reducing onboarding time by 44%.
  • Implemented enhanced review processes, cutting average denial follow-up time by 28% hours, improving operational efficiency.
  • Applied clinical guidelines to ensure appropriate reimbursements for high-cost medical diagnosis, preventing overpayments totaling $10.
  • Streamlined inter-departmental communication channels to improve claim investigation speed, reducing claim lifecycle by 55%.

Affiliations

  • American Association of Managed Care Nurses (AAMCN)
  • American Nurses Association (ANA)
  • National Association of Social Workers
  • National Association of Healthcare Access Management (NAHAM)
  • Society of Women Engineers
  • Association for Supply Chain Management (APICS)
  • American Society of Safety Professionals
  • Toastmasters
  • Commission for Case Manager Certification (CCMC)
  • Healthcare Financial Management Association (HFMA)

Certifications

  • Legal Nurse Consultant Certified (LNCC)
  • Healthcare Risk Management Certification (CPHRM)
  • Project Management Professional (PMP)
  • Certified Business Analysis Professional (CBAP)
  • Certified Public Accountant
  • Salesforce
  • Advanced Qualifications in ICD-10 Coding and Compliance
  • Certified in Healthcare Compliance (CHC)
  • Certified Utilization Review Specialist (CURS)
  • Certified Professional in Healthcare Quality (CPHQ)

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