Objectives And Experiences Obtained Discussion
Obtain a healthcare position where my skills and knowledge can be utilized effectively.
- EXPERIENCE HTM Consultants – Nurse Consultant (Remote) (Owner) 1/15-current
- Recruit/Manage/Supervise clinical and non-clinical staff Quality Assurance Reviews Obtain and manage client contracts – in/outbound sales/Establish and maintain good standing client relationships
- Telephonic Case Manager – Medicare Chronic Care Management/Transitional Care
Management of Remote Patient Monitoring and Annual Wellness Visits involves providing comprehensive support services, conducting assessments, devising care plans, implementing interventions, monitoring and coordinating care, crisis intervention, patient advocacy, and triaging patients. This coordination extends to all members of the case team, including physicians, relevant hospital staff, discharge planners, home health aides/nurses, and social workers. Compliance with HIPAA, patient confidentiality requirements, HEDIS, chart reviews, EMR documentation, and telephonic health risk assessments is diligently maintained.
In the role of a Nurse Recall Audit Contractor (RAC) Consultant, services are provided to physician offices and software companies. The focus is on accurately and efficiently reviewing HEDIS quality measures, ensuring compliance with NCQA guidelines, and utilizing various software applications for abstraction and claims. The objective is to maintain a 95% or better error rate in record abstraction reviews, achieve a high daily production rate, and contribute to enhanced healthcare quality.
As a HEDIS Clinical Coordinator at Datafied, responsibilities include reviewing HEDIS quality measures, mastering HEDIS rules of abstraction, and ensuring compliance with NCQA guidelines. Results of chart reviews are accurately entered into the HEDIS database, maintaining a 95% or better error rate. Contribution to improved healthcare quality and adherence to HIPAA and patient confidentiality requirements are paramount. Additionally, tasks involve assigning charts to abstractors, addressing feedback questions, processing failed charts, and assisting the Project Manager as needed.
In a previous role as a HEDIS Reviewer/Clinical Appeals Nurse at Medlinks, duties encompassed reviewing HEDIS quality measures, maintaining compliance with NCQA guidelines, and utilizing software applications for abstraction and claims. Results of chart reviews were accurately entered into the HEDIS database, and a high standard of error rate maintenance was consistently exceeded. The focus was on contributing to improved healthcare quality, conducting reviews of medical records for insurance claims, and composing appeal letters with supporting evidence.
As a Care Manager at Humana At Home, responsibilities included case and care management, assessment, action plan creation, interventions, care coordination, crisis intervention, patient advocacy, and patient triage. Telephonic and in-home case management, along with HEDIS, chart review, and EMR documentation, were integral components. Coordination with the case team and compliance with HIPAA and patient confidentiality requirements were prioritized.
During a temporary contract as a Nurse Consultant/Prior Authorizations at CIGNA, the focus was on promoting quality and cost-effective medical care. This involved applying clinical acumen to prior authorization requests, performing electronic medical reviews, collaborating with provider networks, and educating providers on utilization and medical management processes. Clinical knowledge was utilized as a resource for non-clinical team staff, and pertinent clinical information was maintained in various medical management systems.
As a HEDIS Overreader Level 2 at Advantmed, the role included accurately and efficiently over-reading EMR abstractions performed by the HEDIS abstraction staff during a seasonal contract.
Develop expertise in all HEDIS rules of abstraction, ensuring all work in compliance with NCQA guidelines Document errors and specific changes made Utilize various software applications to support HEDIS abstraction Accurately entered results of all chart reviews into HEDIS database Maintain 98% or better error rate in record abstraction over-read and data entry
Maintain high daily production rate – exceeded on a daily basis, received weekly bonuses for being Top Performer Contribute to improved healthcare quality Meet routinely with abstraction supervisor and staff to discuss errors and open issues Maintain compliance with all HIPAA and patient confidentiality requirements Altegra
Health – HCC/RxHCC Risk Adjustment Coding (Remote) temp contract 8/15-2/16
Abstract pertinent information from patient medical records. Objectives and Experiences Obtained Discussion
Assign appropriate ICD-9 CM codes, creating HCC and/or RxHCC group assignments as applicable. Assign Flagged Event codes when documentation in the record is inadequate, ambiguous, or otherwise unclear for medical coding purposes. Remain current on medical coding guidelines and reimbursement reporting requirements. Check chart assignments every day and report accurately all hours worked on a weekly basis.
Enter captured data into the risk adjustment coding system. Report work-related concerns to assigned Coder Advocate and if not adequately addressed to Sr. Manager of Clinical Operations. Comply with the Standards of Ethical Coding as set forth by the American Health Information Management Association and adhere to official coding guidelines. Maintain compliance with all HIPAA and patient confidentiality requirements Buckeye Community Health Plan – Community Health Worker (Remote) 6/14-3/16 Provide home or facility visits to risk members and families for evaluation of needs in an effort to provide direction of care for desired outcomes in a cost effective manner.
Community Resource research, outreach for all members, Claims Reviews, Chart Auditing, Chart Abstraction and HEDIS for MyCare Ohio Program Report and monitor specific health & social information back to the case management team including physicians, hospital staff, discharge planners, home health aides/nurses and social workers to assist in development of care, assist with coordination of care Provide telephonic support to members as needed.
Assist members with accessing Page 4 needed services, recognize potentially serious problems to prevent poor health and social outcomes Telephonic assessment completion to all members including entering member documentation into the EMR/medical management system, HEDIS/chart abstraction, and chart auditing.
Coordinate care effectively by completing various tasks using systems such as Impact Pro, CRM, Amisys, Argus, Carestar, Citrix Receiver, LexisNexis, and Trucare, along with Microsoft Office software. Maintain strict compliance with HIPAA and patient confidentiality requirements.
In the role of Medical Billing, Coding & Transcription Services Owner at KC Healthcare from August 1998 to February 2015, responsibilities included offering billing, coding, and medical transcription services to multiple providers. Tasks involved complete coding (ICD-9-CM/CPT), billing and claims, medical transcription, chart abstraction, customer support, software support, and administrative duties such as accounts payable/receivable, payroll, employee supervision, and human resources.
As the Home Health Care Agency Administrator at Healing Hands, LLC from January 2011 to August 2013, duties included supervising all employees, human resources, reviewing all program services, acting as a patient advocate, managing payroll, accounts receivable/payable, medical billing/coding, and conducting case management (telephonic and in-home). The agency served a diverse clientele, including the developmentally disabled, physically, medically challenged, and terminally ill adults and children.
As an Independent Nursing Provider from December 2008 to May 2016, responsibilities encompassed providing skilled nursing and/or personal care in consumers’ homes. This included being a patient advocate, supervising personal care aides and nurses, conducting documentation, dictation, chart auditing, reviewing service plans, and offering medical billing/coding services for multiple independent home care providers.
As a Psychiatric Clinic Nurse at Behavioral Connections Clinic from May 2007 to February 2009, tasks included assisting physicians, medication administration, counseling therapy, daily routine/stat assessments, consultations and reviews with medical staff, documentation, dictation, chart auditing, chart abstraction, prior authorizations, patient triage, and serving as a patient advocate for the developmentally disabled, mentally and physically challenged population.
As a Medical Assistant at Westside Orthopedic Group from February 2001 to February 2005, duties included assisting physicians with various medical procedures, documentation, transcription, chart audits, chart abstraction, prior authorizations, test scheduling, lab cultures, patient orders, medication refills, patient triage, patient advocacy, patient check-in, patient check-out, and scheduling.
In terms of education, currently pursuing an Associate of Arts at Hillsborough Community College and an LPN to BSN at the University of Arkansas. Completed the Licensed Practical Nursing Program at Owens Community College, Findlay, Ohio, and holds an active nursing license for Florida, Michigan, and Ohio.
Possesses various certifications in health-related topics, showcasing a commitment to continuous learning and professional development.
In summary, a self-motivated and highly-efficient Licensed Practical Nurse with extensive experience in various nursing roles, seeking a position in Chronic Care Management, Remote Care Coordination, or Case Management.