Working remotely on various teams within the company, including utilization review, IRR, CDI, Appeals in commercial, Medicaid and CMS RAC. Participate as a party testfying in Administrative Law Judge hearings with the Office of Medicare Hearings and Appeals.

Performed concurrent medical record review to identify areas in the physician documentation that are in need of clarifying to accurately reflect the severity of illness, risk of mortality and level of medical care provided to the patient. Evaluate and determine appropriate primary and secondary diagnosis and procedure codes to assist coding staff determination of appropriate MS-DRG assignment. Communicate in both written and face-to-face interaction with medical and coding staff. Represent area… Show more Performed concurrent medical record review to identify areas in the physician documentation that are in need of clarifying to accurately reflect the severity of illness, risk of mortality and level of medical care provided to the patient. Evaluate and determine appropriate primary and secondary diagnosis and procedure codes to assist coding staff determination of appropriate MS-DRG assignment. Communicate in both written and face-to-face interaction with medical and coding staff. Represent area of specialty at section meetings in addition to developing and providing written and oral education presentations to internal and external stake holders including training of new nursing and physician staff. Show less

Performed pre and post payment review, preexisting medical condition identification, prior authorization and quality of care review. Review of medical record documentation, medical policy and individual member benefit certificate to determine if the medical care/procedures requested met the members benefit certificate as well as medical policy and to ensure services were provided in the most appropriate setting.

Involved in positions with both Medicare and Medicaid contracts leading retrospective and concurrent medical record review. Role encompassed review of medical care given by the provider and utilized by the health care recipient at several inpatient and outpatient settings, as well as identifying misuse of the health care system and potential quality of care concerns and identification of possible fraudulent situations.

Primary role as triage nurse, first to assess patient prior to physician arrival. Obtainedpatient history and completed physical examination. Reviewed medical recordsand provided verbal as well as written report of findings to physician and initiated orders and plan of care. Utilized written and verbal communication with patient, family, and medical staff involved in care to ensure quality care is maintained. Completed daily rounds on patients, telephone triage, patient education and… Show more Primary role as triage nurse, first to assess patient prior to physician arrival. Obtainedpatient history and completed physical examination. Reviewed medical recordsand provided verbal as well as written report of findings to physician and initiated orders and plan of care. Utilized written and verbal communication with patient, family, and medical staff involved in care to ensure quality care is maintained. Completed daily rounds on patients, telephone triage, patient education and coordination of patient care. Assisted physicians with identifying appropriate billing and participated in quality assurance reviews and peer evaluation. Returned part-time 2006-2207 to assist with Electronic Medical Record initiation with converting medical record information and health care details into EMR. Show less

Responsible for providing care to patients in a critical care setting. Later promoted to Unit Manager where in addition to providing patient care also provided direct supervisionof nursing staff in the critical care setting.