Medical Registered Nurse
Resume:
Theresa Witt
Email: abpwok@r.postjobfree.com
Address: **** ** **** ***
City: Portland
State: OR
Zip: 97213
Country: USA
Phone: 310-***-****
Skill Level: Experienced
Salary Range: $60,000
Primary Skills/Experience:
See Resume
Educational Background:
See Resume
Job History / Details:
Theresa S. Witt, RN
abpwok@r.postjobfree.com
PROFESSIONAL SUMMARY
* Over 22 years experience in the field of nursing, culminating in the mixed specialties of
utilization review, some case management, care coordinator in medical/ surgical and psychiatric settings
* Experienced staff RN in psychiatric settings and as an RN for medical -surgical utilization review both for private and federal settings.
* Psychiatric nurse for approximately 12 years in a lock up and open units
* Knowledgeable in aspects of ICD 9, CPT, HCPCS, DRG, and ISD. Proficient in the Interqual Criteria for inpatient medical necessity using the body systems, utilized CMS principles and policy in the position of Medicare B ( researched in the CMS website for confirming current policies, as a complex medical reviewer, and as clinical reviewer for durable medical equipment reimbursement. **( To explain my function in this position, we have to know the DRG from the inpatient records and the ICD-9, the classification of diseases,to be able to evaluate properly and accurately patients history, and to effectively audit providers claims/billings for pre pay (before payment) and post pay (after payment ) for purposes of getting reimbursement from services that were not medically necessary.
* Well informed with experience of health care operations such as admission requirements, and claims.
* Works well individually and self directed.
* Independent and self motivated in studies and research both as individual as well as group or shared studies.
* Recent publication in the AMERICAN JOURNAL OF MEDICAL QUALITY,Vol 12, No.3 1997.
o A shared study regarding the appropriateness of the Interqual Criteria used in the Veterans Administration in West Los Angeles for appropriate acute care admission.) Also initiated a 3 months ER study of the appropriateness of acute and non acute admission through the emergency room.
Core Qualifications
* Computer proficient -
* Data management -entered and maintained a data base for medical necessity using the Interqual Criteria for inpatient admissions
* Reports generation and analysis of the data to the Board of Directors in a quarterly basis.
* Proficiency in private and complex Medicare B utilization review
* RN fraud investigator
Implementation of Interqual criteria for the West Los Angeles VA medical center.
* Proficiency in Medicare B complex medical review and DME.
* Excel in interqual Criteria
Co authored an article - Recent publication in the AMERICAN JOURNAL OF MEDICAL
QUALITY,Vol 12, No.3 1997. ( A shared study regarding the appropriateness of the Interqual
Criteria used in the appropriateness of the Interqual Criteria used in the Veterans Administration.
* Registered Nurse, diploma, AA & AS
* BA credited to BS by International Evaluation of transcripts.
Experience
National Heritage Corporation/ EDS / Hewlett Packard LA, CA
Review Nurse Analyst 12/2004 aaa 01/2011
aa Complex Medical Review for Medicare Baaa review of medical records of providers on pre pay review and other abused CPT codes and for medical necessity for services billed. Then transition to post pay review for medical necessity.
aa Policy RN-assisted in research and development and revision of policies of the insurance carrier incorporating with current CMS rules.
aa Medical support personnel -for the non clinical employees. Participated in the post pay process to get reimbursement for medical claims that was not medically necessary, or an option to make a case for a Federal investigation.
aa Initiated post pay medical reviews for providers submitting claims that was not supported in medical records.
aa the company jurisdiction changed and was transitioned to a DME - durable medical equipment (2008) review carrier and reviewed medical necessity of requested DME in our jurisdiction. This company was then relocated to another state.
St. John Health Center Santa Monica, CA D
DOU Case Manager 2002
aa Emergency room and DOU case manager
National Heritage Insurance Company/ Electronic Data System 2001-2002
aa Same function as from Trans America ( merged or bought out by EDS /NHIC). Title remains as RN reviewer for complex medical claims and billings of Medicare B.
Well Point /Blue Cross Insurance Company LA, CA
RN Reviewer 12/2003 - 12/2005
aa Workmanaaas Comp - 3rd party Utilization review for medical necessity for Spinal Surgery for the Workman Compensation. Pre review for requested spinal surgery and communicated information to surgeons to validate medical necessity.
Trans America Insurance Co. LA, CA
RN Analyst 01/2000 aaa 2001
aa Medical Review for Medicare B- review of medical records of providers on pre pay review and other abused CPT codes and for medical necessity for services billed.
aa Policy RN-assisted in research and development and revision of policies of the insurance carrier incorporating with current CMS rules.
aa Other departmental transitions; Investigator and retro medical records review, (clinical resource, for other non clinical investigators).
aa Pre- pay review for problem and sanctioned providers medical records before reimbursement or payment.
aa As a fraud investigator, we developed cases for investigation for referrals to OIG and if applicable for the FBI.
aa We also develop cases for overpayment and reimbursement of services not rendered or not medically necessary under the Medicare guidelines.
aa DME clinical reviewer- Reviewed medical necessity for durable medical equipment claims from DME providers, and participated in post pay and then transitioned to post pay review for medical necessity
Veterans Administration West Los Angeles, CA
UR//QM analyst, 1991-12/1999
aa UR/QM Specialist- chart audits and special research studies/projects.
aa Inpatient pre-admission, and transfer clinical coordinator - helps facilitate an efficient and seamless patient transfer to appropriate treatment specialty or appropriate ward or unit.
aa Other collateral duties are to help out chart review for peer review and for inappropriate continuing length of stay
aa Extensive experience in Psychiatry settings, especially in intensive and locked up units in county, federal and private facilities
aa Co authored a publication in AMERICAN JOURNAL OF MEDICAL QUALITY,Vol 12, No.3 1997.
MGM-UNIHEALTH Chatsworth, CA
RN benefit coordinator 12/1991
aa Mainly utilization review for 5 different groups of (IPA).
aa Function is to process and coordinate patient care, as well as to process and expedite inpatient and outpatient referrals.
aa Also reviews claims of questionable billings for accuracy and appropriateness of billed amount
PRUDENTIAL INSURANCE Woodland Hills, California
Psychiatric RN reviewer 12/1989 - 12/1991
aa Utilization review and care coordinator, as well as health consultant for Psychiatric inpatient adults and adolescents
aa Review questionable billing claims from contracted facilities for accuracy and appropriateness of charges.
aa Utilized the DSM (Psychiatric diagnostic criteria) for proper level of care and treatment
aa Recipient of numerous commendations from customers as well as promotions and cash bonuses from this employer
OLIVE VIEW MEDICAL CENTER Roxford, CA
Psychiatric staff nurse 1989
aa Full time staff nurse in a psychiatric adult locked up unit.
aa Duties involved accurate and efficient timely medication, and management of problem behavior in the unit.
aa Some scattered per diem experience of home health from different home health agencies
Education
ASSOCIATE OF ARTS AND SCIENCE ANTELOPE VALLEY COLLEGE, Lancaster, CA
AA, AS 1984
COLLEGE OF THE CANYONS, Valencia, CA
Diploma RN 1988
Silliman University, Dumaguete City, Negros Oriental, Philippines
Bachelor of Journalism 1968
International Evaluation Inc., Culver city, CA, USA
awarded the US equivalent of Bachelor of Science
Professional Affiliations and Licenses
RN CALIFORNIA LICENSE
RN OREGON LICENSE
RN WASHINGTON LICENSE
AMERICAN NURSES ASSOCIATION
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