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Skills

  • Acute care expertise
  • Strong clinical judgment
  • Case management
  • Patient care coordination
  • Patient and family advocacy
  • Healthcare quality assurance
  • Healthcare audit mechanism creation
  • Claims Management
  • Analytical thinking and data interpretation
  • Authorization gap resolution

Work Experiences

  • Achieved 15% accuracy.
  • Acted quickly in situations that threatened the unit's safety and security, implementing crisis prevention interventions to control and de-escalate the situation.
  • Adapted documentation procedures.
  • Addressed trends in denied claims.
  • Analyzed high-dollar claims data.
  • Achieved $12 in cost savings over three years.
  • Achieved 10 savings per quarter.
  • Balanced an average caseload of 4 daily service requests while maintaining a 49% approval accuracy rate.
  • Addressed patient care issues such as discharge delays, procedures that were postponed, and discharge equipment that was unavailable.
  • Achieved a department award for exceptional performance in 2015.

Summaries

  • Achieved 42% fewer failures.
  • Successfully led unit-based groups to improve care delivery and patient satisfaction.
  • Proven track record of using critical thinking, analysis, and medical knowledge to provide exceptional care in high-pressure situations.
  • Considered to be a hard worker with a strong desire to succeed.
  • Dedicated, hardworking, and experienced category Registered Nurse with experience in patient care, medication monitoring, and treatment management.
  • Budget management is something I'm very familiar with.
  • Achieved a 54% success rate.
  • Professionally trained with cross-functional collaboration and performance reporting abilities.
  • Excellent track record of resolving issues, increasing customer satisfaction, and driving overall operational improvements.
  • Achieved $12 in cost savings by collaborating with medical directors to review and validate high-cost specialty treatments.

Accomplishments

  • Provided analytical reports to upper management detailing utilization metrics, leading to informed policy changes and an 53% improvement in operational efficiency.
  • Managed escalated cases, resulting in a 47% improvement in claim approval turnaround time without increasing denial rates.
  • Monitored patterns in claim denials and identified key areas for training, successfully reducing denial rates by 33% in one year.
  • Developed comprehensive reporting tools using procedure, resulting in greater transparency across the authorization and approval process.
  • Reduced claim denial rates by 45% by conducting regular training sessions and audits with medical and nursing teams.
  • Managed stakeholder relationships, ensuring seamless communication between internal teams and external insurance providers.
  • Resolved product issue through consumer testing.
  • Facilitated consistent communication between eligibility teams and clinical staff to promptly resolve insurance-related issues, increasing workflow efficiency by 72%.
  • Documented and resolved framework which led to standard.
  • Collaborated with team of 16 in the development of system.

Affiliations

  • Institute for Healthcare Improvement (IHI)
  • Society of Human Resource Management
  • American Marketing Association
  • American Association of Medical Auditors (AAMA)
  • American Association of Healthcare Administrative Management (AAHAM)
  • Society of Women Engineers
  • Academy of Health Care Management (AHM)
  • American Medical Informatics Association
  • International Association of Administrative Professionals
  • American Association of Nurse Auditors (AANA)

Certifications

  • Certified in Care Management (CCM) - category
  • Certified Revenue Cycle Representative (CRCR) - category
  • Health Care Compliance (HCCA) Certification
  • Certified Specialist in Managed Care (CSMC) - process
  • Certified Compliance & Ethics Professional (CCEP) - framework
  • Certified Case Manager (CCM) - Commission for Case Manager Certification (CCMC)
  • Lean Six Sigma Black Belt Healthcare Certification
  • Certified Pharmaceutical Healthcare Management Professional - standard
  • Certified Health Data Analyst (CHDA) - framework
  • Apple Certified Associate (ACA)

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