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Skills

  • Claims Denial Reduction Strategies
  • Case Assignment Workflow Optimization
  • Care Review Software Proficiency (e.g., Jira)
  • Communication with Healthcare Providers
  • Workflow automation implementation
  • Problem-solving and critical thinking
  • Onboarding Efficiency Improvement
  • Review Protocol Standardization
  • Chronic Disease Case Protocol Development
  • Data-driven decision making

Work Experiences

  • Recorded all interactions and entered authorizations into a system that stores sensitive information about medical authorizations and claims for patients.
  • Conducted thorough pre-review analysis.
  • Achieved 53% higher agreement rates.
  • Achieved a 35% overturn rate on claims.
  • Actively participated in the negotiation process between primary stakeholders and insurance companies, leading to an improvement of 18 in reimbursements for complex care scenarios.
  • Contributed to the team winning the Employee of the Year in recognition of outstanding customer service and compliance with state healthcare regulations.
  • Actively participated in negotiations with stakeholders and insurance companies.
  • Audited case reviews weekly.
  • Assisted other departments with projects as needed.
  • Achieved a 34% decrease in compliance issues.

Summaries

  • Enhanced care delivery outcomes.
  • Collaborated with internal audit teams to ensure regulatory standards like HIPAA and CMS were met, contributing to a 81% reduction in compliance violations.
  • Dedicated professional with a passion for transforming care service delivery through strategic utilization of workflow automation and process improvement methodologies.
  • Achieved a 31% on-time closure rate.
  • Enforced compliance with standards such as HIPAA and CMS.
  • Achieved $16 cost savings.
  • Conducted data analysis.
  • Conducted thorough Medicare/Medicaid record reviews.
  • Contributed to a 13 reduction in unnecessary procedures.
  • Applied cost-benefit analysis techniques to maximize clinic efficiency and reduce healthcare overutilization, saving the organization 11 through targeted initiatives.

Accomplishments

  • Reduced average care review processing times from 11 days to 3, improving the division's turnaround KPIs and patient treatment response times.
  • Successfully handled escalations and resolved 50% of contested claims, contributing to increased customer satisfaction.
  • Achieved consistent performance benchmark results by processing 16 cases per day while maintaining a 50% accuracy rate.
  • Enhanced team performance by conducting regular process improvement sessions, reducing claim inaccuracies by 74% and improving compliance.
  • Spearheaded a project to enhance case assignment workflows using AI-driven tools, cutting manual case distribution efforts by 48% within 2015.
  • Coordinated a comprehensive audit of review cases, identifying errors that reduced turn-backs on reviews, improving accuracy by 59%.
  • Integrated Power BI into the care review process, improving case assignment workflow accuracy by 45%, streamlining operations.
  • Led the pilot implementation of SAP, increasing the efficiency of care authorizations by 60% and reducing overall manual effort.
  • Played a leading role in training department staff on the latest care review software and processes, increasing overall team productivity by 13 cases per week.
  • Managed end-to-end coordination of care reviews for 13 cases monthly with a 49% success rate in adhering to established turnaround times.

Affiliations

  • Attended, Annual National Conference on Utilization Review Practices, featuring keynotes on workflow optimization and reduced readmissions.
  • Attended, National Association for Healthcare Quality Conference (NAHQ), gaining insights into process improvement and patient safety initiatives.
  • Member, Organization of Nurse Executives (ONE), contributing to thought leadership on nursing practices and managed care service delivery improvements.
  • Member, Association for Utilization Management Executives (AUME), contributing regularly to strategy discussions regarding future utilization management best practices.
  • Certified, Utilization Review Accreditation Commission (URAC), for demonstrating expert-level knowledge in utilization review and care authorization standards.
  • Active Participant, American College of Healthcare Executives (ACHE), with a focus on healthcare policy, transformational leadership, and improving patient outcomes.
  • Participant, Institute for Healthcare Improvement (IHI) training programs on clinical guidelines and healthcare cost management.
  • Active Member, Integrated Care Resource Center (ICRC) mailing list, focusing on state and federal strategies for coordinating care for dual-eligible beneficiaries.
  • Member, Nursing Management Congress (NMC), attending annual conferences to learn about innovations in care review and patient flow processes.
  • Member, National Association for Healthcare Quality (NAHQ), collaborating with peers to improve healthcare quality measures and regulatory compliance.

Certifications

  • Health Information Technology Certification (HITC) – Northwind, 2022
  • Certified Clinical Coder (CCC) – standard, 2018
  • Certified Professional Coder (CPC) – AAPC (American Association of Professional Coders), 2022
  • Accredited Healthcare Fraud Investigator (AHFI) – National Health Care Anti-Fraud Association, 2021
  • Lean Six Sigma Green Belt in Healthcare – method, 2020
  • Medical Claims Reviewer Certification – metric, 2024
  • Certified Professional in Utilization Review (CPUR) – framework, 2017
  • Clinical Documentation Improvement Specialist (CDIS) – method, 2016
  • Master Certification in Health Administration (MCHA) – Meridian, 2019
  • Health Care Compliance Associate Certification (HCCA) – Ironclad Systems, 2021

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