Amber Wilcher Email & Phone Number

Populations: Subacute, HIV, Substance Abuse Disorders, Mental Health ,Behavioral HealthPractices within the scope of the Nurse Practice Act. Assesses, plans directs and evaluates total nursing care as determined by the residents/patients age-related physical, psychosocial, and cultural needs.Insures privacy for patient confidentiality of condition and personal information. Demonstrates an ability to remain calm, perform effectively and professionally during peak periods of activity and emergencies.

Clinical experience in: Subacute, Substance Abuse Disorders, Mental Health, Geriatrics ,Behavioral HealthResponsible for presenting, preparing, and submitting all recommendations for approval or denial to the medical director and plan liaison. Review physician documentation and medical records to determine if proposed treatment plan is medically accepted clinical review criteria Coordinate medical record-related tasks for Healthcare Effectiveness Data Information Set (HEDIS). Perform a variety of assignments to support team members and leaders. Collaborate with team members to ensure that all medical record reviews are accurately completed and meet intended quality. Recommend certification of proposed treatment plan and issue authorization letters or if not supported, refer for peer clinical review physician. Using clinical expertise, reviews clinical information and clinical criteria to determine if the service/device meets medical necessity for the member.

Maintaining quality customer service by following customer services practices. Prepares reports by collecting, analyzing, and summarizing information. Analyzes insurance claims to prevent fraud. Manage expedition of appeals via problem solving and collaboration with other departments. Negotiate claim settlements and verify insurance coverage

Intensive Case Management (Population: Mental and Behavioral Health, Substance and Addiction)Provide advocacy for clients by monitoring client contact with outside agencies. Accurately implementing and documenting care plans.Experience in maintaining patients records. Reviewing and interpreting lab reports and preparing care plans, Prior authorization, Experience with Medicare , Medicaid and Commercial health plan. Verification of ICD-10 coding and accuracy.