• Performs clinical/medical reviews of retrospective medical claim reviews utilizing InterQual criteria to ensure medical necessity and appropriate/accurate billing and claims processing.• Identifies and reports quality of care issues.• Assists with Complex Claim review including DRG Validation, Itemized Bill Review, Appropriate Level of Care, Inpatient Readmission, and any opportunity identified by the Payment Integrity analytical team; requires decision making pertinent to clinical experience• Documents clinical review summaries, bill audit findings and audit details in the database• Provides supporting documentation for denial and modification of payment decisions.• Independently re-evaluates medical claims and associated records by applying advanced clinical knowledge, knowledge of all relevant and applicable Federal and State regulatory requirements and InterQual guidelines.• Reviews medically appropriate clinical guidelines and other appropriate criteria with Medical Directors on denial decisions.• Supplies criteria supporting all recommendations for denial or modification of payment decisions.• Serves as a clinical resource for Utilization Management

At Cambridge Healthcare, I spearhead the development of managed care processes, focusing on case management and social services to ensure compliance and improve outcomes. I oversee the implementation of these processes, training case managers to ensure fiscal responsibility and clinical accountability. I lead financial reviews to ensure adherence to managed care processes, identifying and addressing missed opportunities. Conducting environmental inspections to evaluate facility performance is a key responsibility, helping maintain standards and compliance. Additionally, I provide input on case management and social services, ensuring alignment with best practices and regulatory standards. I deliver materials on managed care practices and regulations to various departments, enhancing operational efficiency. I play a pivotal role in training new case managers and Social Services Directors, fostering a culture of continuous improvement. My active participation in Joint Operation Committee (JOC) and Quality Care meetings involves creating rehab and clinical outcome reports. I conduct reviews of facility financials and managed care outcomes, discussing findings with case managers and administrators. Lastly, I manage care contracting and payor relations, securing optimal terms and conditions for facility partnerships.

At St. Mark's Hospital, I delivered nursing care in the Medical/Surgical ICU, specializing in post-operative care for cardiac and neurosurgical patients. I managed care for a diverse range of critical care patients, performing all interventions within the scope of practice. Expertly managing ventilated and sedated patients, I ensured optimal outcomes through meticulous monitoring and intervention. I administered pharmacological drips and managed arterial lines, central lines, and other invasive lines with precision. I collaborated effectively with multidisciplinary teams to provide and manage comprehensive care for critically ill patients. Additionally, I educated patients and family members on critical care processes and at-home care, promoting informed decision-making. Providing compassionate end-of-life care was a key responsibility, ensuring comfort and support for patients and their families. I conducted thorough patient assessments, accurately documenting care activities and updating charts in the computer system. Stabilizing patients experiencing emergency complications utilized my advanced critical care skills and protocols. I also implemented treatment plans for acute and chronic conditions, coordinating diagnostic tests and specialist care as needed.

HoAt Salus Homecare, I collaborated with business management to identify, formulate, and implement compliance risk education and training policies, procedures, and controls. Ensuring clinical and regulatory compliance was a major focus, particularly on survey preparedness and developing post-survey plans of correction. I conducted compliance risk assessments, identifying root causes of exceptions, and developing corrective action plans. Monitoring compliance activities and generating detailed monthly and quarterly regulatory reports were critical components of my role. I developed, initiated, maintained, and revised policies and procedures for the Compliance Program. Coordinating compliance activities across all departments and reporting progress and challenges regularly was part of my responsibilities. I played a key role in developing goals and objectives for department quality improvements. Reviewing billing procedures, claims, and collection processes ensured compliance with federal and state regulations. I organized and presented compliance reports to the Governing Board quarterly, ensuring transparency and accountability. Serving as the primary contact for all Utah Payor Issues and Collections helped maintain smooth operations.me Health, Home-care, and Hospice

At Sun Mar Healthcare, I led the development and implementation of managed care strategies, ensuring alignment with organizational goals. I negotiated contracts with insurance providers, securing favorable terms and compliance with contractual obligations. Directing a team of managed care professionals, I provided leadership, mentorship, and performance evaluations. I developed and monitored key performance indicators (KPIs) to assess the effectiveness of managed care programs. Implementing utilization management guidelines and protocols optimized patient care and resource utilization. I collaborated with clinical teams to ensure seamless integration of managed care practices and patient care services. Conducting regular audits and reviews of managed care activities helped identify areas for improvement and ensure compliance. I provided training and education to staff on managed care policies, procedures, and best practices. Preparing and presenting reports to senior management on managed care performance, challenges, and opportunities was a critical aspect of my role. I played a key role in strategic planning and policy development, contributing to the overall growth and success of the organization. Developing and maintaining relationships with payors ensured effective communication and collaboration. I managed the budget and financial aspects of managed care operations, ensuring cost-effective management and optimal resource allocation.

At Kindred Healthcare, I conducted market analysis to identify potential growth opportunities and develop strategic business plans. I established relationships with key stakeholders, including physicians, healthcare providers, and insurance companies. Collaborating with regional and local teams, I developed and implemented marketing and outreach programs. Analyzing business performance metrics to identify trends, opportunities, and areas for improvement was a key part of my role. I provided training and support to facility administrators on business development initiatives and strategies. Additionally, I developed promotional materials and presentations to support business development efforts. Coordinating with clinical teams to ensure alignment of business development strategies with patient care goals was essential. I managed and tracked business development budgets, ensuring efficient use of resources and adherence to financial targets. Organizing and participating in community events and networking opportunities helped promote Kindred Healthcare services. Successfully increasing patient referrals and expanding market presence contributed to overall business growth.