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Skills

  • Knowledge of federal and state healthcare regulations
  • Tracheostomy care
  • Medical billing and coding knowledge
  • Manual and automated tracking systems
  • Insulin medication assistance
  • Women's health exams
  • Advanced proficiency in category
  • Knowledge of health insurance claim processes
  • Electronic Medical Records (EMR) proficiency HubSpot
  • Multilingual patient support (program)

Work Experiences

  • Reported findings to quality departments and collaborated with the team to develop corrective actions for any deficiencies after conducting routine restraint audits.
  • Achieved a 39% win rate on appeals in 2016.
  • Achieved a 27% lower rejection rate over procedure.
  • Achieved a 30% increase in first-pass submissions.
  • Oversaw 11 nurses and nursing activities in a 6-bed hospital, providing comprehensive nursing guidance and ensuring high levels of patient satisfaction and care.
  • Maintained quality standards by conducting routine medication audits and adhering to internal and industry best practices.
  • Followed strict safety precautions by calculating the correct dosages before administering medications.
  • Achieved a 33% success rate in overturned denials.
  • Conducted ongoing assessments to assess mental health needs and collaborated with a multidisciplinary team to create, implement, manage, and modify individualized care plans.
  • Gave medications and treatments to patients and tracked their responses while collaborating with healthcare teams to adjust treatment plans.

Summaries

  • Leader who prioritizes quality and efficiency.
  • Accomplished leader in cross-functional training programs, presenting on prior authorization strategies that resulted in a 73% increase in approval rates and team performance metrics.
  • Achieved a 42% approval rate.
  • Successfully led unit-based groups to improve care delivery and patient satisfaction.
  • Prior Authorization Nurse is a multi-talented Prior Authorization Nurse who is consistently rewarded for planning and operational improvements.
  • Recognized for motivating management team members to achieve their goals and fostering innovative work environments.
  • Dedicated, hardworking, and experienced procedure Registered Nurse with experience in patient care, medication monitoring, and treatment management.
  • Board-certified registered nurse with interests in telemetry, medical-surgical, and behavioral health.
  • Dedicated to learning, growing, and succeeding in Miscellaneous.
  • Within Miscellaneous, senior Prior Authorization Nurse and outstanding performer in project management and process improvement.

Accomplishments

  • Authored educational materials for nurses and physicians on prior authorization best practices, reducing unnecessary appeals by 70%.
  • Created a metrics-driven dashboard for tracking prior authorization requests, reducing manual follow-up actions and decreasing overall case processing time by 65% days.
  • Developed a cross-functional communication approach with pharmacists, resulting in a 34% reduction in treatment delays due to pending authorization.
  • Established an efficient tracking system to monitor prior authorization and appeals processes, reducing time-to-completion for cases by 18%.
  • Contributed to the implementation of a Power BI system, increasing the efficiency of prior authorizations and reducing staff workload by 52% hours weekly.
  • Led process improvement initiative, reducing prior authorization submission errors by 65%, which resulted in a President's Club from framework in 2023.
  • Collaborated with insurers and healthcare providers to resolve 16 escalated cases monthly, resulting in an increased first-pass approval rate of 22%.
  • Improved payer relations by developing clear communication protocols, increasing positive outcomes in escalated cases by 51%.
  • Utilized framework to ensure accurate documentation and streamlined processing, reducing administrative errors by 47%.
  • Used Microsoft Excel to develop inventory tracking spreadsheets.

Affiliations

  • Jaycees
  • Association for Clinical Documentation Integrity Specialists (ACDIS)
  • American Association of Managed Care Nurses (AAMCN)
  • Freemason
  • Association for Computing Machinery
  • National Association of Subspecialty Physicians (NASP)
  • American Medical Billing Association (AMBA)
  • Association for Supply Chain Management (APICS)
  • International Association of Administrative Professionals
  • Health Information and Management Systems Society (HIMSS)

Certifications

  • Cisco Certified Network Associate (CCNA)
  • ServSafe
  • Cisco Certified Internetwork Expert (CCIE)
  • Certified Public Accountant
  • Certified Prior Authorization Specialist (CPAS)
  • Accredited Case Manager (ACM) Certification by Beacon Labs
  • Certified Public Accountant (CPA)
  • CompTIA Security+
  • Certified Professional in Healthcare Risk Management (CPHRM)
  • Certified in Health Plan and Coverage Coding by Vantage

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