Lori T. Email & Phone Number

My initial career began as a Caseworker Counselor after earning my Bachelors; while I first became an EMT-B and then an NREMT-P, I soon discovered that I wanted more than ever to become a full-time healthcare worker, and earned my RN.My first experience was in Labor and Delivery in a Level III High-Risk Maternity Hospital. It was here, during stat c-sections, that I realized I loved the Operating Room. I then transitioned to our Children’s Hospital and quickly found my niche in ENT, Orthopedic, and Neurology specialties, although I was cross-trained in all.I now am a Clinical Auditor and currently have my BSN; and this is my favorite position of all, although, if I had to pick face-to-face patient care, the Operating Room is my favorite.

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  Bsn, Clinical Auditor

  Upmc Health Plan

  Dec 2014 - Present - Pittsburgh, Pennsylvania, United States

  Initially beginning in Utilization Management, completing training in Telephonic for Acute and Post Acute cases, covering Medicare, Medicaid and Commercial lines of business, transitioned to Electronic Acute and Post-Acute accounts for 7 facilities, portal as well as via canopy accounts, accessed via ERecord, Epic, and Cerner.Single-handedly updated the Medical Policies for the Health Plan for Medicare's current LCD and NCD updates, and monitored them monthly, in strict communication with the Medical Directors and Senior Medical Directors. Serve as a Clinical Auditor entrusted to comply with CMS and NCQA guidelines for documentation compliancy, as well as complete various internal audits on a rolling continuum. Currently manages internal worklist daily as assigned. Completes various audits, including but not limited to: monthly Medical Director, departmental audits, and random selected cases as assigned. Completes daily Denial letters within compliance regulations with regards to CMS, DHS, and NCQA guidelines. Participates in monthly meetings.Was one of a team of four who created the current SharePoint site in 2016, now utilized Corporate-wide.Assisted in auditing IRRs, InterQual audits and reviews, and Denial Letters for all lines of benefits, with additional instruction and training as required. Responsible for reviewing medical records to determine whether documentation substantiates the medical necessity, quality of care, and utilization. A nurse auditor insures that data collection for reporting purposes from various departments is within charging practices and departmental policies. Ensures optimal billing methods that meet with billing compliance standards (regulations).Knowledge of CPT, ICD10-CM.