Quality Assurance Medical

Nina Ram

Email: abpn82@r.postjobfree.com

Address: *** ******** *****

City: Taneytown

State: MD

Zip: 21787

Country: USA

Phone: 240-***-****

Skill Level: Management

Salary Range: $75,000

Primary Skills/Experience:

See Resume

Educational Background:

See Resume

Job History / Details:

NINA RAM, RN MS

MEDICAL RECORDS REVIEWER

UR & CASE MANAGEMENT

* DISEASE MANAGEMENT

* Taneytown, MD * Tel 240-***-**** * abpn82@r.postjobfree.com * www.NinaRam-RNMS.vpweb.com

Highly skilled medical professional with extensive experience focusing on quality improvements,

the administrative processes, and education, with specialized experience in comprehensive

care management and utilization review.

* Consistently delivers robust bottom line results while ensuring the highest levels of quality validation standards.

* Creative, innovative, and forward thinking - adept at handling complex challenges with thoughtful and clearly defined strategies that ensure high performance.

* Works effectively in environments of intense pressure requiring high levels of sensitivity and proficiency.

* Adheres to the strictest levels of regulatory compliance, maintaining meticulous documentation and records.

* Conversant in Bulgarian and Spanish.

Core Competencies

* Case Reviewing * Mentoring * Process Improvement * Project Management

* Quality Assurance Records Management * Regulatory Compliance

* Team Leadership * Training/Development

Professional Experience

Advanta Government Services, Annapolis Junction, MD 2012 - Present

MEDICAL RECORDS REVIEWER (part-time)

Performing retrospective electronic medical chart reviews of Medicare Hospital & HomeHealth cases, following set CMS (Centers for Medicare & Medicaid Services) benefit guidelines, utilizing the Plan of Care requirements and certification elements, along with the data elements of the UB-04 hardcopy billing, and the 837 electronic billing,, processes.

Key highlights

* Knowledge of the general principles governing reasonable and necessary hospital medical services, and skilled nursing homehealth services, thereby applying it to specific situations of services provided, and the corresponding billing for those services.

* Familiar with INTERQUAL Level of Care Criteria Acute Care guidelines, and the OASIS payment methodology utilizing the e-ROVER software, to guide and support the reviewer's examination of the documentation in the medical record (thereby verifying that the servicing agency-completed bill is valid and reflective of the patient's condition at the time assessment was performed).

* Averaging 3-4 electronic appeals or chart reviews per hour utilizing these protocols, thereby recording where and when supporting or contradicting information appears in the medical record by providing a narrative appeals report, or checklist of validation if homehealth, for each situation/item assessed (for the ultimate purpose of bill review and provider education).

Healthways, Columbia, MD 2004 - 2011

COMPREHENSIVE CARE MANAGER (CCM)

Optimized the effectiveness of patient treatment plans through the development and delivery of educational programs following the guidelines of evidence-based medicine. Conducted telephonic motivational interviewing to establish educational needs of non-hospitalized, high-risk/acuity insurance members with chronic medical conditions (diabetes, heart failure, coronary artery disease, asthma, COPD, chronic kidney disease, etc.), thereby developing individualized comprehensive care plans effectively addressing specific functional and emotional needs. Provided on-call services for clients across the US, answering after-hours questions as well as coordinating emergency care.

Key highlights

* Proactively pursued cross-training in all products/services across the business to maximize operational effectiveness and population penetration by averaging 3 completed calls per hour, as one of the few multi-licensed RNs with life insurers in CA, NV, and MA.

* Created an environment of high performance for new nursing staff, training and mentoring them on strategies and best practices to consistently deliver high-quality patient care as a CCM.

* Increased the effectiveness of patient treatment strategies by liaising with other health plan professionals to provide comprehensive services, including nutritionists, behavioral health/insurance case managers, and local emergency medical services.

* Improved treatment outcomes and increased overall health, by slowing/mitigating the progression of disease by developing and delivering highly informative education on wellness via phone, mail, and Internet.

ADP / Integrated Medical Solutions, Rockville, MD 1996 - 2003

SENIOR UTILIZATION REVIEW NURSE, TEAM LEAD

Built on an extensive clinical and administrative career history, and following ABQAURP guidelines, able to evaluate medical necessity and/or appropriateness of services rendered for retrospective reviews of medical records for the property and casualty industry. Concurrently reviewed and analyzed medical records for proper use of ICD-9 and CPT codes. Developed and produced reimbursement recommendation letters for claims adjusters, going beyond established metrical guidelines.

Key highlights

* Led and motivated review team members in the best practices to streamline the inter-office triage medical review process, achieving a review time of 24-48 hours, thereby exceeding all client contractual obligations.

* Consistently promoted accurate and timely review of medical claims/records, facilitating the maintenance of a 96% production rating and 98% quality rating.

* Laid the foundation for future employment opportunities of the displaced nursing staff by coordinating an agreement between Montgomery College and InterQual for CPUR and CPUM training/certification.

Staff Builders, Washington, DC 1994 - 1995

UTILIZATION REVIEW CLINICAL SUPERVISOR

Delivered performance-focused direction in maximizing the operational effectiveness of 100+ direct patient care workers treating up to 200 Medicare and Medicaid homecare clients weekly across Maryland and the District of Columbia. Provided ongoing training and mentoring to homecare staff,

ensuring critical compliance with government regulations and company standards required for continued reimbursement and accreditation.

Key highlights

* Guided the office in successfully achieving the first JCAHO Accreditation with Commendation, as assistant to the Quality Assurance Director.

* Continually maintained compliance with Medicare and Medicaid guidelines for reimbursement and accreditation by developing and implementing the Active Patient Tickler System, a computer application alerting and tracking recertifications, caseload summary reports, and progress note notifications.

Additional Experience

Director of Clinical Services, Olsten Kimberly Qualitycare, White Plains, NY

* Ensured branch compliance with Licensed Home Care Services Agency guidelines as defined by New York State DOH regulations and company standards.

Patient Care Manager, Westmoreland Hospice, Greensburg, PA

* Developed and delivered OSHA Blood-borne Pathogens Standard In-service for all hospice team members.

Home Care Manager, Jacob Perlow Hospice, Beth Israel Medical Center, New York, NY

Inpatient Unit Manager, Ritter-Scheuer Hospice, Bronx, NY

Nursing Supervisor / Branch Manager, Staff Builders, Flushing, NY

* Led the branch to receive its first New York State DOH LHCSA license.

Staff Nurse, Oncology/Bone Marrow Transplants,

Montefiore Medical Center, Bronx, NY and Yonkers General Hospital, Yonkers, NY

Education & Professional Development

Master of Science, RN / Family Nurse Practitioner, Pace University, Lienhard School of Nursing Graduate Division, Pleasantville, NY

Bachelor of Science, Biology / Pre-Medicine, Roanoke College, Salem, VA

LICENSURES / CERTIFICATIONS

Registered Professional Nurse (RN) License:

New York by examination (NCLEX = eligible for licensing in any state) - inactive

Maryland, Pennsylvania, Massachusetts, California, and Nevada by endorsement - active

BLS & ACLS - American Heart Association by Rescue One Training for Life, Inc. (certified 2012)

CLNC - Medical-Legal Consulting Institute, Inc. (certified 2001-2005)

CPUR, CPUM - McKesson Health Solutions LLC (certified 2003)

ABQAURP Certified Diplomate - American Board of Quality Assurance and Utilization Review

Physicians, Inc. (certified 1996-2003)

PROFESSIONAL ORGANIZATIONS / AFFILIATIONS

Marquis Who's Who in Medicine and Healthcare(R) (1997 - onward)

Strathmore's(R) & Worldwide Who's Who(R) (2012 - onward)

INFORMATION TECHNOLOGIES

Windows and Microsoft Applications

Working knowledge of the MILLIMAN Care Guidelines

MEDICAL CODING planned for 2013 (ICD9 /10 & CPT Certification)

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