RN

Sheri R. Messina, RN

**** ******* ***, ********, ** 30064

(h) 770-***-****

(c) 770-***-****

email: *******@***.***

EDUCATION

Gilmer High School; Gilmer, Texas; Graduated June 1971

Baylor University; Waco, Texas; Academic Courses; August 1971 – May 1972

Kilgore Junior College; Kilgore, Texas; Academic Courses; August 1973 – August 1975

Lamar University; Beaumont, Texas; Associate Degree of Nursing; August 1978 – August 1982

EMPLOYMENT

Dates/Firm/Location Positions/Responsibilities

Contract: Senior Medicare Audit Analyst

September 2011-December 2011 Review Medicare claims for medical necessity. PRGX is a Recovery Audit

Fulltime: company with a contact with CMS to Review and recover overpayments

January 2012-May 2013 to providers for Medicare Beneficiaries. Review medical records for

PRGX medical necessity resulting in overpayments/underpayments to providers

Atlanta, GA to return overpayments to Medicare using CMS rules and regulations as

guidelines. Reviewing for proper coding and billing practices as well as

medical necessity. Also review for first level denial discussion requests

from providers.

October 2007-July 2010 Case Manager Optum Health

United Health Care-Optum Health Telephonic case management for a dedicated account, Call members and

Atlanta, GA get their health background information in order to try and assist member

with their healthcare needs. Make sure they are on the correct

medications for their conditions and that they are seeing the correct

providers for their conditions as well. Do admission counseling prior to

planned admissions and talk with members on their discharge from the

hospital to see if members have any healthcare needs. Interface with

physicians, social workers and others to coordinate care for members.

April 2007-August 2007 Appeals Analyst/National Clinical Appeals Unit

Aetna Insurance Reviewed denied claims for appeals from both providers and members.

Alpharetta, GA Reviewed for medical necessity utilizing Milliman Care Guidelines and for

compliance with State/Federal regulations, as well as for compliance with

each individual companies benefits. Present cases to MD panel on a

weekly basis.

July 2005 – February 2007 Senior Medicare Audit Analyst

PRG Schultz Reviewed Medicare claims for medical necessity. PRG Schultz is a

Atlanta, GA Recovery Audit company with a contact with CMS to Review and recover

overpayments to providers for Medicare Beneficiaries. Reviewed medical

records for medical necessity resulting in overpayments/underpayments

to providers to return overpayments to Medicare Trust Fund using CMS

rules and regulations as guidelines. Reviewing for proper coding and

billing practices as well as medical necessity.

January 2003 – May 2005 Claims Review Nurse

Affiliated Computer Services Reviewed denied claims/appeals for physicians from Georgia Medicaid

Atlanta, GA program. Utilizing AMA Code Manager for NCCI, McKesson Claims

(Fiscal agent for Georgia Check software program, as well as Georgia Medicaid criteria, and

Medicaid) recognized industry standards. Reviewed medical records submitted by

providers, including operative reports, hospital notes, delivery notes, as

well as meet the criteria set forth by the Georgia Medicaid program, for

Sheri R. Messina, RN; Page 2

Dates/Firm/Location Positions/Responsibilities

the CPT and ICD-9 codes applicable.

July 2001 – August 2002, Health Care Consultant

Aetna Insurance Pre-certification, telephonic review utilizing M & R, and Interqual criteria

Alpharetta, GA for inpatient, outpatient hospitalizations, DME, Home Health Care liason

with all Home Health Care Companies in Georgia and Florida dealing

with Case Managers on continuing Home Health Care cases, as well as

interface with physicians and other departments such as Case

Management, Disease management, Discharge Planning and

Concurrent review, and complete pre-determinations for medical review.

October 1996 – June 2000, Office Nurse

Piedmont OBGYN, Greenville assisting doctors with interview, physical assessment, patient examinations,

Health Corp., Greenville, SC medical history, and any office procedures, such as coloposcopies, hysteroscopies,

cervical biopsies and LEEP procedures as well as surgical pre-certification with

insurance companies.

August 1993 – November 1995, Health Services Case Manager

Health Services RN, Healthsource Do all pre-certification for the Greenville area hospitals. Telephonic

of SouthCarolina Greenville, SC review of all impatient emergency admits to the Hospital. Precert all

elective surgical procedures with doctors offices both in and outpatient,

coordinated home health care with the hospital discharge planners, social

workers and/or physician's offices for home services, such as IV meds,

home physical therapy education of patient and families on new

medications and procedures. Code procedures utilizing both CPT and

ICD-9 coding.

January 1990 – August 1993, Utilization Review Specialists

Utilization Review Specialist, Review all Medicare/Medicaid and Medically indigent patient charts for

Greenville Memorial Hospital, medical necessity. Guidelines used are from Medicare Standards

Greenville, SC governed by the South Carolina Peer Review organization - Carolina

Medical Review. Each case is reviewed for both Severity of Illness and

Intensity of Service. The position includes interfacing with physicians,

nursing staff and social services as well as most ancillary services in the

hospital. Also Pre-certification receive verification of benefits contact

review companies and review the chart for all the clinical information and

telephone review to certify the hospital stay.

March 1988 – May 1989, Office Office Nurse

Nurse, Greenville Kidney Center Assisting doctors with interview, physical assessment, patient

Greenville, SC examinations, medical history, and any office procedures; running 12-

Lead EKG and Bone Densitometry measurements on all hemodialysis

and peritoneal dialysis patients; drawing blood for laboratory tests on

private patients. Receiving and returning patient telephone calls daily;

scheduling appointments for patients with our office doctors, as well as

referrals; interfacing with both hospital and outpatient dialysis unit

personnel. Ordered all supplies and dealt with all pharmaceutical

representatives; instructed patients on

medications, diet, exercise and disease processes, as well as provided

psychological support for patients and their families.

May 1987 – December 1987, Case Manager RN

Case Manager, RN, Physicians Manager over case load of 60-80 home health care patients. Duties

Visiting Nurse Service included initial physical, medical and social history of new patient,

Beaumont, TX including vital signs; contacting Medicare for frequency and duration of

home health visits; obtaining doctor's orders; providing doctor's office with

Sheri R. Messina, RN; Page 3

Dates/Firm/Location Positions/Responsibilities

updates and changes in patient's condition; doing surgical dressing care

and decubitus care; starting and maintaining home IV therapy,

chemotherapy, parental nutrition, subclavian catheter care; administering

IV, IM and PO medications; writing Medicare orders and updates and

updating patient charts, team conferences, and care plans; making

regular and supervisory in-home visits.

LICENSURE

Georgia # R152089

WORKSHOPS

National Teaching Institute's AACN Convention, New Orleans, Louisiana, May 1983

Interpretation of 12-Lead EKG.

Hemodynamic Monitoring in the ICU.

Nutritional Status of the Critically Ill.

Renal Assessment of the Compromised Patient

Interpreting Heart Sounds

The Changing Role of Critical Care Nurses in the Hospital Setting

DHEC Workshop - "AIDS and the Medical and Dental Office Staff", Greenville, South Carolina

REFERENCES

References available upon request.

Contact this candidate