Denise D. Virag, RN, BSN

*** ******** *****

Lower Burrell, PA 15068

724-***-****

PROFESSIONAL EXPERIENCE

Clinical Reviewer Medical Review Part A - Novitas Solutions, Inc. (formerly

known as Highmark Medicare Services) _October 29, 2012 - Present

. Analyze and reviews complex healthcare pre and post pay claims data

and appeals from a medical perspective.

. Conducts and renders a clinical decision concerning the validity of

health care claims and levels of payment based on the Center for

Medicare and Medicaid Services (CMS), medical necessity, utilization,

national and local policies, Social Security Act, and appropriateness

of care as well as accepted medical standards of practice.

. Initiates and conducts one: one regional educational calls involving

discussions with Healthcare leaders and CMS leaders in accordance with

Medicare Progressive Corrective Action.

. Works within multiple computer applications such as the Fiscal

Intermediary Standard System (FISS), Highview, InterQual, and Oracle

systems; Internet and Microsoft Windows applications.

. Meet workload expectations in a timely manner per CMS requirements.

. Excellent organizational, investigative, and analytical skills.

. Strong understanding of coding systems such as ICD-9, HCPC, CPT

medical codes.

. Excellent oral and written communication skills and the ability to

handle highly sensitive issues with the utmost professionalism and

diplomacy.

. Assumes the role of preceptor to assist and instruct new staff

members.

. Coordinates timely and accurate responses for all providers under

review.

. Works with informatics and other workgroups to obtain relevant

statistical analysis for reviews.

. Analyze and interprets requirements of the Social Security Act, Code

of Federal Regulations, and other program requirements.

Clinical Nurse II - West Penn Allegheny Health System, Pittsburgh, PA

Medical-Surgical Nursing/Obstetrics &

Gynecological Nursing

Western Pennsylvania Hospital _ August

1999 - March 2013

Allegheny Valley Hospital _ July 1990 - August 1999

. Responsible as charge nurse for overseeing patient care, staff

assignments, emergency response and management of patient crises.

. Displayed expert clinical skills within the unit to patients with

medical emergencies, trauma, surgical, and obstetrical interventions.

. Instructed educational classes to staff and revised policy &

procedures as a committee member.

. Experience with computer systems SUNRISE, CHAS, McKesson, and GE

Centricity software documentation programs.

. Exceptional capacity to multi-task, manage competing priorities with

ease while fostering delivery of direct patient care towards adult,

geriatric, and labor/post-partum/nursery patients.

. Contributed to strategic plans and initiatives to advance standards of

care excellence, improve patient outcomes and drive continuous

improvement.

. Gathered and analyzed clinical data for Highmark Perinatal Project

through the Western Pennsylvania Hospital Labor & Delivery Department.

Certified School Nurse Substitute - Burrell School District

Kiski Area

School District

December 2003-January 2013

Certified School Nurse - Pennsylvania Leadership Charter School,

Pittsburgh, PA 2008-

2009 School Year

. Maintained a comprehensive health record for each student including

immunizations, results of tests and screenings, and physical and

dental examinations.

. Interpreted the health needs of children, and assisted families with

community resources to meet their children's health needs.

. Administered medication to students as requested by parents or

physicians according to the medication guidelines.

. Collected health information and completed all data entry as requested

by the Department of Health and Department of Education.

EDUCATION

Slippery Rock University, Slippery Rock, PA

Professional Educator Certificate School Nurse K-12

December 2003

Penn State University, New Kensington, PA

Bachelor of Science in Nursing

May 1998

Citizens General Hospital School of Nursing, New Kensington, PA

Nursing Diploma

June 1990

CREDENTIALS & AWARDS

Sigma Theta Tau International Honor Society

Alpha Sigma Lambda Honor, Penn State

Penn State Alumni Association

Bell-Avon Alumni Association Scholarship Award

Registered Nurse License, State of Pennsylvania

CPR Certification

Professional References available upon request.

Contact this candidate