Nurse Auditor
Resume:
VICKI WEAVER, RN
RESUME
Vicki Weaver
***********@*****.***
Customer- focus Professional
Detail Oriented
Clinical Compliance Expert
Nurse Leader
Vicki Weaver
Kennesaw, GA 30144
678-***-**** (H)
***********@*****.***
Customer-focus Professional Employee Development Organizational Leadership Sr. Project Manager / Clinical Compliance Expert / Nurse Leader. Extensive clinical and managerial background/ Extensive knowledge of and experience with URAC, NCQA/HEDIS, Acute Care, Oncology, Trauma, Case Management, Utilization Management, Complex Care, and Disease Management in the Managed Care and hospital environment. Consistently, successful in using my skills and abilities to mentor clinical support staff, professional nurses, and ancillary staff to promote innovative clinical practices resulting in positive health outcomes.
CORE COMPETENCIES:
• Multi-task & Work Well
Under Pressure
• Performance
Guarantees/Budget
• Performance
Metrics/Audits
• Project Management/Project
Lead
• Organizational Culture
Change
• Strong Communication
Skills
• Problem Solving & Decision
Making
• Effective Hiring &
Retention
• Detail Oriented
/Priority Setting
EDUCATION
Associate Degree (1992): Kilgore College, Nursing
Bachelor of Science: Completed course work at University of Phoenix, Phoenix, AZ - Nursing Professional Licensure: TX RN (Compact State) & GA RN (current); MD RN (Not Current) PROFESSIONAL EXPERIENCES
EGUICLAIM; Change Healthcare
Nurse Auditor – Charge Audits 3/17 – current
• Audit Medical Records
• Evaluate Claims data for compliance with designated payor / Federal guidelines
• Evaluate Bills (IBills / UBs) for accuracy /completeness as well as for audit potential.
• Provided expertise to Provider contacts
• Perform virtual Desk Audits and Onsite Audits
• Coordination of Activities (Onsite Audits)
• Planning
• Scheduling
• Travel
• 1:1 Reviews / Sign Off
• Manage assigned Caseload, ensuring timely process, exceeding productivity goals /metric
• Ensure consistent application of all Guidelines i.e., Payor, Federal, State, Facility, Equiclaim etc.
• Perform other functions as needed;
• Bill Breakdown
• Support Leadership Team as requested
• Support Administrative staff to ensure compliance with protocols ANTHEM (formerly WellPoint), Atlanta, GA
Business Change Manager / Business Change Manager, Sr. 3/11 – 3/17
• Supported Clinical Ops Director and ensured activities were aligned with corporate strategies and Clients requirements.
• Identified potential issues, project change, and scope data.
• Project owner and led efforts to meet or exceed performance guarantees processes.
• Provided expertise to the leadership team and business partners and supported the execution of the operational plan.
• Collaborated with leadership team to develop unit specific toolkit / unit specific policy / procedures and developed strategies for process improvement.
• Supported Management with Monitoring Staff productivity utilizing applicable systems (CCPulse) and developing reports (Scorecards).
• Project lead of implementation of unit specific Scorecards.
• Management of Case Management (CM) / Utilization Management (UM) Quality and Compliance process / initiatives for Clinical Operations
• Facilitated orientation of new hires to UM / CM program descriptions.
• Active member of Enterprise-wide Quality Improvement Committees and Regional Compliance Committee; monitoring and reporting metrics.
• Mentored associates interested in project management career.
• Performed Audits (Quality, Claim Based, Performance Guarantee) and raw-data research: includes MD and nursing documentation, adherence to assigned standards and operational guidelines and metrics.
• Responsible for Administered Accreditation / Regulatory / Compliance training and responsible for Accreditation Compliance; NCQA / HEDIS and URAC.
• Worked with interdisciplinary team members to create / develop processes; Training and Development, Accreditation, IT Development / Support.
• Responsible for determining the accuracy of the outcome of claim payment decisions.
• Member of sub-committee assigned to review coding practice r/t “bundling”, incorrect coding. HIGHLIGHTS OF PROFESSIONAL EXPERIENCES
ANTHEM BCBS (formerly WellPoint)
Condition Care Medical Manager 7/2009 – 3/11
ALERE HEALTH IMPROVEMENT (formerly Matria), Marietta, Ga. 3/06 – 7/09 Operations Supervisor – Evening Shift
LEGACY MEDICAL CENTER, Atlanta, GA 6/05 – 3/06
Director of Emergency and Critical Care Services
COMPREHENSIVE MEDICAL ASSOCIATION, Atlanta, GA 1/05 – 11/05 & 4/07 – 11/07 Director of Medical
SOUTHWEST HOSPITAL & MED. CENTER, Atlanta, GA 11/04 – 1/05 & 5/00 – 11/011 Critical Nurse Manager, Critical Care Educator
PARKLAND HEALTH AND HOSPITAL SYSTEM, Dallas, TX 2/03 – 11/04 Compliance Officer/ Nurse Recruiter
RHD MEMORIAL MEDICAL CENTER, Dallas, TX 1/01 -2/03 Clinical Manager Oncology-Orthopedic Med./Surgery
WORK EXPERIENCES
• Supervised the clinical and non-clinical staff activities for a Call Center involved in Disease management and Wellness education. The staff supervised includes: Enrollment, Care Managers, Case Managers, Community Resources, Depression, and Registered dietitians.
• Monitored staff schedules, managed time and attendance, and staff productivity utilizing applicable tools (Report Cards) / system.
• Provided training and oversight of member Complaints process and members’ emergency calls
(Accreditation standards) to leadership team.
• Managed and performed QA activities involving: Service Recovery, Quality Alerts, Event reporting and follow up.
• Developed and revised Policy & Procedures for HED Emergency Calls Management and Scheduling and Staffing (GMT).
• Maintained compliance of HED protocols and Policies and Procedures. Reviews all new and revised policies and presents to the Management team once a month.
• Revised Clinical Policy and Procedures for NCQA audit. Participated in NCQA audit representing Critical Care / Trauma areas.
• Facilitated orientation and training of staff including Supervisors / Managers. Teaches Emergency Management to NHO. Worked with Leadership in addressing staff issues and concerns.
• Created Quality Call monitoring tools that were unit specific and client specific.
• Director of 10 bed ICU (to include hemodialysis), a 10- room Emergency Department with 3 trauma rooms, and Nurse Manager of 10 bed ICU and acute hemodialysis.
• Responsible for the capital budgeting, inventory, hiring, orientation and preceptorship
• Supervised 20 to 80 FTE’s involved in the management of chronic medical illnesses.
• Monitored and maintained compliance of all clinical staff, hiring, counseling, orientation, and staff education on Chronic Care Guidelines.
• Member of the Nursing Scope of Practice, Policy and Procedure, CQI, Pharmacy and Therapeutics Committees.
• Organized and implemented a Critical Care Orientation Internship Program.
• System Administrator for the Automated Nurse Staffing/Scheduling Office System.
• Maintained and monitored integrity of data entered in the automated system.
• Trained managers/directors and designees (end-users) to use of and interpretation of ANSOS data including productivity, licensing, certification and credentialing data for all nursing staff.
• Completed random audits for staff compliance per standards (hospital/state/federal), rules and regulations.
• Member of PI / QA team to improve clinical performance and submitted data to regulatory agencies.
• Responsible for verbal and written reporting of compliance activities.
• Responsible for reporting to Chief Nursing Officer (CNO) updates (monthly, routinely) related to industry appropriate (licensed / certified) staffing, budgetary measure related to staffing and scheduling, etc. Information also submitted to Dallas County Commissioners Office.
• Managed productivity, maintained floor budget, scheduled staff, counseled staff, PI / QA, training and education.
• Administered chemotherapy and biotherapy to oncology patients. Maintained Certification in Chemotherapy.
TECHNICAL PROFICIENCIES
Microsoft Office: Word, PowerPoint, Excel, Access, and Outlook and various electronic clinical documentation systems
PROFESSIONAL AFFILIATES
American Association of Critical Care Nurses
Emergency Nurses Associations
Medical Lead - Cobb / Douglas County Medical Reserve
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