Claims Reviewer for Retro and Large Billing >$250K

Reviewer for pre-authorizations for various MCR advantage plans for home health and PAC settings. Using Interqual and CMS guidelines to reach effective decisions of needed care.

RN UM in PH OP Department

Served as the Tennessee state wide and west Tennessee regional trainer for the LTSS Choices program educating social workers and nurses as new hires of various LTSS positions and existing staff on an ongoing basis for program changes and updates using classroom, virtual classroom, video-teleconferencing and tele-conference platforms. Developed curriculum and agendas for training courses on Medicare, MCO’s, Medicaid, Choices program and benefits, assessments, person centered care plan development with goals, care coordination, telephonic interviewing using motivational interviewing techniques, managing members with chronic/ acute illnesses, behavior health, appropriate need of hospital and ED utilizations, cost effective alternatives, smooth transitions throughout healthcare continuum such as hospital to home, hospital to rehab to home or nursing facility to community, claim/authorization management, continuous review for effective care for goals, member need, medical necessity and satisfaction as well as cost, collaboration of team members such as PCP’s, home health, DME, utilization review, nursing facilities, hospitals and rehab units. Used creative educational techniques to train employees and distribute informational resources for their knowledge base. Use problem solving techniques to train and assist persons supported by Amerigroup and providers in resolving conflicts and establishing working relationships. Worked and trained member advocate and provider relation liaison for Choices LTSS program. Participated in ERR audits of members for Quality Improvement. Served as field preceptor for new hires and care coordinator with member case load as well. (See description below).

Point of contact for coordination of all physical health, behavioral health and other home and community based services for LTSS community and NF members supported by UHG. Conduct thorough and objective initial and ongoing face-to-face assessments of the member at home and in NF within specific mandated intervals to determine current status and needs, including physical, behavioral, functional, psychosocial, financial and health status expectation. Conduct telephonic, outreach and complete additional assessments as needed to address member change in condition. Identify members with potential for high-risk complications and coordinate appropriate supported self-care in conjunction with the member and care coordination team. Act as an advocate for an individual's care needs by identifying and communicating opportunities for care interventions, including identifying and addressing functional deficits and gaps in care. Management of critical transitions, supporting discharge planning staff at hospitals, rehab facilities and LTC facilities with member transition to home setting. Develop and implement targeted strategies to improve health, functional or quality of life outcomes, such as population health or pharmacy management. Proactively educate members about the program, including opportunities for consumer direction of HCBS and obtain necessary consents for participation. Identify, plan and obtain health and wellness goals. Attended and participated in Advocacy and AAAD meetings on a regular basis. Participated in community outreach projects and health fairs. Appointed mentor/preceptor duties and team lead for advisement/training for other team members. Conducted audits for the state and internal audits for quality improvement for members.

Responsible for placement and recertification of Clinitron and other pressure relief support surfaces, granting approval for products based on diagnosis, assessments, clinical necessity and payer requirements. In collaboration with sales force to market, educate, and train various pressure relief surfaces for the home and the insurance guidelines to place qualified clients. Managed and monitored patients to assure ongoing qualifications of products based on continued clinical assessments and review. Developed relationships and communication with resources to ensure patient and provider satisfaction such as physicians, home health agencies, wound care clinics, discharge planners, LTC facilities, hospitals and other DME to promote quality care of patients. Created plans of care for continued success of healing patients’ wounds and promoting overall improvement of health needs. Worked with private insurance, Medicaid and Medicare on payer requirements, coding and guidelines for various surface products. Highest profit margin team established for the Homecare branch for 3 successive years.

Responsible for comprehensive and simple pulse oximetry testing and assessment in the home of clients. Marketing pulse oximetry testing in the home for independent patient use to resources. Independent duties include account management, patient scheduling, travel, patient training of the equipment use, data input, downloading and communication and education of test results to physicians, patients and other referral sources.

Responsibilities in all aspects of management of home health cases and staff for 2 locations. Responsible for staff development. Trained personnel on any updated equipment and technology. Office and personnel coordination. Coordination of all staff for each discipline including RN’s, LPN’s, PT, OT, and CNA’s. Evaluation of all staff members quarterly. Establishing development plans for staff to obtain growth for their job performance, patients’ care and office performance. Developed plans of care for patients. Conducted skilled nurse visits for various patient needs i.e. wound care, med administration, trach care, and HHA needs. Marketing responsibilities to physicians, case managers, social workers and discharge planners. Exceeded market profit goals each consecutive year.

Staff liaison between staff, residents, family and physicians. Weight supervision program for all residents and care coordination of care plan for all residents. Acquiring equipment and in-servicing staff for residents. Working closely with physicians for re-certification of residents for LTC continuation of benefits in the facility and adherence to insurance guidelines for MCR, Medicaid and private pay. Responsible for rehab program and quality improvement of resident outcomes. Marketing and representing the facility at community fairs and public gatherings.

Marketing and sales rep of home oxygen, resp equipment, CPAP, BiPAP, and other durable medical equipment including the respiratory/disease management programs which accompany the product to the referral sources of physicians, home health companies, hospital discharge planners, LTC facilities, patients, staff nurses and caregivers. Improving patient outcomes and gross profits by reducing held sales, obtaining new accounts, maintaining current accounts, and improving marketing strategies by creative means and education. Participated in marketing fairs, community health fairs and respiratory conventions. Responsible for center's respiratory programs and patient tracking. Quality Improvement monitoring as well to increase quality of life in patients' long and short term health goals.

12 years full time experience in Respiratory ICU, with 8 years as agency nursing in various locations in Memphis hospitals with experience in emergency, med-surg, neuro, burn unit, trauma, SNF's and general ICU's. Experience in rural hospitals with emergency, ICU head nurse, med-surg, ambulance RN and surgery.