Manager Insurance

Lisa Beach *** West Highland

Tecumseh, OK *****

405-***-**** *********@*****.***

Professional Summary:

** *****’ experience as a Clinical Nurse Auditor and 15 of those years as a Regional Manager. Regional manager of 14 hospitals with 20 employees.

Expertise in reviewing medical records and identifying lost revenue for facilities.

Coordination of department managers and facilitate course of actions to improve documentation. Familiar with commercial and private insurance carriers and educated the staff on each contract

Familiar with several hospital computer systems.

Seeking a position of increased responsibility and authority.

Licenses

LPN

Skill Highlights

Developed matrix of all insurance carriers

Educated staff on matrix breakdown

Worked closely with Business office manager with AR days

OIG and RAC audit experience

Knowledge of HMOs, Medicare and Medi-Cal

Medical Manager Software

Managed care contract knowledge

Responsible for continuation of contracts in my facilities

Electronic Medical Record (EMR) software

CPT and HCPCS coding

HIPAA compliance

Medical billing software

Strong planning skills

Strong work ethic

Team player with positive attitude

Deadline-driven

Good written communication

Exercises good judgment

ICD-9 coding

Professional Experience:

Think HealthCare Solutions

February 2015 to April 2017

Clinical Nurse Auditor;

Helped facilities set up protocol on charging practices

Educated the hospital staff on importance of documentation to help with reimbursement

Maintained strict HIPPA guidelines while performing remote audits

All previous auditing experiences, listed below were utilized to achieve current contract obligations

Conducted audits as previous National HealthCare Review audits were preformed

Performed specific audits as directed by the CFO

Clinical Nurse Auditor III/Regional Manager

July 1991 to October 2014

Adreima (previously National HealthCare Review) - Phoenix, AZ

Carefully reviewed medical records for accuracy and completion as required by insurance companies.

Strictly followed all federal and state guidelines for release of information.

Acted as a liaison between the business department, billers and third party payers in resolving billing and reimbursement accuracy.

Demonstrated knowledge of HIPAA Privacy and Security Regulations by appropriately handling patient information.

Appropriately and correctly identified errors and re-filed denied/rejected claims as they were received from the Patient Account Representative.

Analyzed and interpreted patient medical and surgical records to determine billable services.

Posted charges, payments and adjustments.

Ensured timely and accurate charge submission through electronic charge capture, including the billing and account receivables (DAR) system and clearing house.

Meticulously tracked and resolved underpayments.

Performed OIG and RAC audits.

Regional Manager duties included:

Start up and maintaining several contracts with facility CFO and business office manager

Training and supervising new employees.

Communicate with department managers and hospital administration

Coordinated and established protocol for all departments.

Meetings with clients and department managers discussing audit findings and suggestions

of proactive steps to improve reimbursement issues.

Cost analysis on implants including markup values compared to market cost

Extensive analysis of charge master to identify duplicate entry, price review, and description comparison to department inventory

Remote work covering 4 time zones with monthly and bi-monthly webinars

Client communication via remote contact with monthly narrative reports to accompany monthly data

Meetings with client at each facility covering 5 states performed monthly included department managers and hospital staff responsibly for charge entry and generating invoice pricing along with hospital cost.

Conducted remote audits with insurance companies including complying needed documentation to increase and prevent potential loss of revenue. Audits performed off site which lessen the cost to the facility.

Monitored client invoices including clarification and immediate adjustments of audit focus to maximize client’s return on investment.

Worked closely with department managers to identify areas of historical reimbursement difficulty and implemented changes to increase revenue.

Retrospective audits preformed for accuracy and data complying to assure concurrent auditing profitability and sustainment.

Utilization of supplies in offsite outpatient wound care areas and cost analysis comparisons to contracts.

Comparative audits performed on outpatient areas contracted to the facility to insure all areas of contractual agreement were consistent and accurate.

Physician audits conducted with comparisons of supplies required to perform specialized surgeries and / or new surgery procedures.

Bundle supply review audits to identify potential loss of revenue.

Education:

AIU---undergrad work in Marketing and Project Management

References:

Upon request

Contact this candidate