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Skills

  • Medical Record Analysis
  • Quality assurance in medical reviews
  • Inpatient care utilization monitoring
  • Claims overturn success rate
  • Family planning services education
  • ICD-9 forms
  • Tracheostomy care
  • Evidence-based clinical documentation
  • Peer review protocol development
  • Chronic disease management

Work Experiences

  • Achieved improvement over 2019.
  • Updated patient charts with data such as medications using HubSpot in order to keep records current and support accurate treatments.
  • Aided in the development of an appeals process that successfully overturned 47% of initial adverse determinations through collaborative documentation.
  • Achieved Top Performer by maintaining a compliance rating of 79% during framework audits of case management practices.
  • Assessed treatments using HubSpot.
  • Oversaw and managed 9 clinical and support staff in patient care activities while maintaining a high level of staff morale and professionalism.
  • Physical assessments, medication, and chronic disease management were all part of my care for home health patients.
  • Gave patients, families, and caregivers information on diagnosis and prognosis, treatment options, disease process and management, and lifestyle choices.
  • Oversaw nursing activities for 6 departments at a 5-bed hospital with 2+ employees, advising nurses on how to provide excellent patient care and satisfaction.
  • Achieved system across multiple departments.

Summaries

  • Proven track record of using critical thinking, analysis, and medical knowledge to provide exceptional care in high-pressure situations.
  • Achieved over 26% improvement in audit readiness.
  • 4 years of experience in medical records analysis.
  • Expert in all aspects of patient care, with a track record of success in collaborating with multidisciplinary teams to develop care plans aimed at assisting patients in recovering from medical or surgical procedures as well as managing complex mental illnesses.
  • During each shift, an attentive nursing professional provides a high level of care, patient assistance, and vendor management.
  • Adept at facilitating peer-review protocol development.
  • Dedicated, hardworking, and experienced system Registered Nurse with experience in patient care, medication monitoring, and treatment management.
  • Achieved procedure.
  • Clear understanding of strategic planning and stakeholder engagement as well as cross-functional collaboration training.
  • Registered Nurse, North Carolina Board-Certified, with 9 years of experience providing high-quality care to patients in metric and framework care units.

Accomplishments

  • Researched and proposed updates to standard, improving alignment with industry standards and lowering the likelihood of denied claims by 32%.
  • Conducted retrospective analysis of denied claims and identified 2 cases eligible for appeal, leading to an additional $120,000 in revenue.
  • Generated weekly utilization reports using Tableau, providing actionable insights that assisted in reducing costs by $129,000 while ensuring adherence to clinical guidelines.
  • Collaborated with case management and physician teams to create streamlined workflows, reducing overall treatment approval time by 50%.
  • Resolved product issue through consumer testing.
  • Successfully overturned denial decisions on appeal by utilizing up-to-date clinical guidelines, recovering $28,000 in underutilized benefits for the organization.
  • Trained and mentored 14 new Concurrent Reviewers on the use of Asana, resulting in 53% faster claim resolution times.
  • Contributed to the successful accreditation by method, aligning utilization review processes with stringent compliance standards.
  • Analyzed and tracked UM performance metrics, identifying areas of improvement and directly contributing to 40% efficiency gain in clinical workflow management.
  • Reviewed and made recommendations on 4 high-cost treatment plans, saving the organization $168,000 while maintaining quality patient care.

Affiliations

  • American Nurses Credentialing Center (ANCC)
  • Association of Nursing Professional Development (ANPD)
  • American Society of Safety Professionals
  • Utilization Review Accreditation Commission (URAC)
  • Association for Computing Machinery
  • Association for Healthcare Administrative Professionals (AHCAP)
  • National Association of Healthcare Revenue Integrity (NAHRI)
  • Case Management Society of America (CMSA)
  • American Organization for Nursing Leadership (AONL)
  • Accreditation Commission for Health Care (ACHC)

Certifications

  • Google Certified Professional Cloud Architect
  • Certified Legal Nurse Consultant (CLNC)
  • Cisco Certified Internetwork Expert (CCIE)
  • Certified Healthcare Access Manager (CHAM)
  • Project Management Professional (PMP)
  • Certified in Healthcare Compliance (CHC)
  • Certified Documentation Improvement Practitioner (CDIP)
  • Cisco Certified Network Associate (CCNA)
  • Certification in Health Insurance Portability and Accountability Act (HIPAA)
  • Certified in Medical Necessity (CMN)

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