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Revenue Integrity Analyst, CDI, HEDIS Nurse,Utilization /Case Mgr

Location:
Suitland, Maryland, 20746, United States
Posted:
October 26, 2018

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Resume:

Charlene Leak

**** ******* ******

Apt. #****

Camp Springs, MD 20746

ac7iai@r.postjobfree.com

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

OBJECTIVE: It is my ultimate goal to obtain a challenging position with opportunities for advancement while providing the absolute best customer care and satisfaction.

EXPERIENCE:

10/2016 01/2018

Technology Automation Management, Inc.

Nurse Auditor

Identified all professional services that occurred in all clinics of privileged providers, including inpatient and outpatient professional services. After audits were completed, took appropriate actions to improved coding quality based on issues identified. Performed integrity revenue audits. This included updating data collection tools, giving feedback to providers and coders, educating providers on documentation and coding, training providers, providing access to current coding books, revising system templates, and developing system change requests to correct problems inherent in the hardware or software of the system. Experienced utilizing 3M CCE, CHCS, AHLTA, Essentris, Microsoft Windows, Outlook, Word, Excel, Access, and Internet Explorer. Knowledge of Military Health Care System, medical terminology, creating and deleting files, searching files and records, storing and extracting material from a variety of software packages, including word processing software, and generates cumulative, statistical, tubular, narrative and graphic reports. Audited clinical documentation and created and implemented corrective measures for clinical accuracy for providers as needed.

Knowledge of data collection methods for basic health care, research information and statistical reporting, laws and regulations on the confidentiality of medical records. Skilled in effective oral and written communication key functions and expected performances, operating automation equipment, medical record procedures, regulations and principles to carry out a variety of medical records functions such as analysis, coding auditing, auditing, including compliance, and compiling data. Experienced with in-depth knowledge of IDC-9/10-CM, CPT, HCPCS, M-DRG's, APC's, medical dictionaries, manuals relating to coding textbooks and glossaries rule changes. Extensive knowledge for understanding and applying official coding clinic guidelines, medical terminology, anatomy and physiology usage, including general medical, surgical, pharmaceutical, hospital terms, and abbreviations and abstracting techniques.

8/2016--10/2016

Evolent Health

Utilization Review Nurse

Obtained baseline health information about the child from an assessment questionnaire conducted with the member and family at an enrollment interview. The case manager utilized this to facilitate the development of a multidisciplinary written plan of treatment in collaboration with the member, family, PCP, and other appropriate professionals. The plan of treatment was developed within the first sixty days of coverage. Preauthorized appropriate services and procedures based on physician’s plan of care orders. Processed denials and appeals. Performed clinical charge nurse duties. Created and implemented corrective measures for clinical accuracy for providers as needed.

12/2015 6/2016

MSN Health/United Healthcare

HEDIS Nurse Auditor

Performed chart reviews for various insurance companies in order to ensure compliance of patients and providers as well as obtained proof of services performed and billing submitted. Performed integrity revenue audits monthly, in order to confirm clinical documentation improvement. Independently conducted audits of medical record documentation compared to patient charges on a concurrent and retrospective basis. Itemized claims, validated with medical records, and reported documentation deficiencies, billing errors, and trends to the appropriate department heads in writing or e-mail. Performed initial and follow up assessments regarding the inpatient provider’s documentation skills. With each assessment, inpatient record reviews shall include verification of patient identification and demographics; reason for admission; disposition date; assignment of diagnoses; procedures documentation and health care provider’s signature. Identified opportunities for improvement to ensure documentation used for measuring and reporting physician and hospital outcomes was accurate and complete.

Performed a baseline review of all inpatient health care providers in order to determine if there was a positive impact on documentation improvement, as well as a baseline review of all new health care providers within 30 days of seeing patients to determine the current level of documentation detail and a report of findings provided within a specified amount of days of starting the review.

Concurrently reviewed all medical records identified in the task order(s) to identify documentation deficiencies. For an inpatient stay, reviewed the provider documentation daily and recommended an addendum to the record if necessary. If it was determined, a provider’s documentation was not improving, recommended a corrective action plan to identify specific areas of improvement, a remediation plan that included a timeline in which to achieve positive results and a follow up plan and the corrective action plan approved prior to implementation. A summary of all providers placed on a corrective action was included in the monthly report of services rendered. Performed focused inpatient medical record reviews and the initial review performed within 24-48 hours of patient admission.

Communicated with physicians, case managers, coders and other health care team members in order to obtain comprehensive medical record documentation for accuracy, to support the severity of illness, expected risk of mortality, and complexity of care provided to the patient. Documentation obtained included clinical treatment and procedures, medical decisions and diagnoses for inpatients.

Initiated a query to the health care provider to clarify and explained any documentation that did not clearly and consistently describe the patient’s medical condition and hospital stay to assign the correct MS-DRG. Clarification included obtaining accurate and complete documentation based on current clinical findings, prescribed treatment, medical interventions and conducted routine (non-query) follow-up reviews of the medical record until the issue was resolved.

Reviewed outstanding queries daily for provider responses and followed up as needed to facilitate timely and accurate documentation. Provided education to physicians and other members of the health care team regarding compliant documentation responsibilities, coding and reimbursement issues and documentation guidelines.

Investigated and analyzed documentation issues/questions to generate and recommend solutions to the Task Order Government POC. The contractor shall prepare formal reports for the government with findings and recommendations regarding documentation, revenue and reimbursement issues. Provided medical record documentation education to providers, residents and interns.

Implemented coding documentation improvement processes and disseminated new/updated information to improve documentation, RWP and Prospective Payment System (PPS) capture within five (5) business days after receiving approval.Educated the health care provider on the most efficient process for capturing data in the applicable system.

Evaluated Present on Admission (POA) indicators for each diagnosis that could potentially affect the principal diagnosis, quality indicators or MS-DRG assignment. validated data using government AIS’ and identified data capture trends, variations in coding practices and performed management analysis. Used this data to provide feedback to taskers or queries from customers in a variety of formats. Monitored compliance with policies and procedures relevant to the clinical data management program, made recommendations to improve compliance, obtained approval for implementation and took action. Collected and analyzed data to correct identified complex coding deficiencies and improved reimbursement capture. Utilized enterprise prescribed tools to monitor the completeness of clinical documentation and accuracy of code assignments.

- made daily rounds and interacted with health care team members to ensure consistent documentation practices. The contractor shall seek clarification from physicians regarding proper documentation as it relates to reimbursement. Created and implemented corrective measures for clinical accuracy for providers as needed.

Reviewed daily departmental charge reports. Performed clinical nursing at various inpatient/outpatient facilities. Investigated and resolved charging and coding questions raised by Patient Financial Services and clinical personnel including assessment of documentation to support charges, accuracy of services billed, edits, etc. Certified CCS Coder. Worked in coordination with the Revenue Integrity coders and CDM department. Executed concurrent audits of claims to ensure the correctness of the financial record and accuracy of clinical documentation. Utilized ICD-9/10 and CPT coding as well as HCPCS coding. Processed denials and appeals.

06/2010--03/2015

RSI/Trusted Health Plan

Nurse Case Manager

Recruitment Staffing Inc.

LPN Case Manager/Utilization Review Nurse

Utilization Review Nurse/Hospital Care Coordinator/Discharge Planner

Performed utilization review and preauthorized various services by using both Interqual and Milliman. Provided discharge planning and hospital care coordination for Medicaid managed care members. Certified CCS coder. Utilized ICD-9/CPT coding as well as HCPCS coding. Clinical documentation specialist. Provided case management for high risk obstetrical patients and NICU babies as well as children with special needs. Processed denials and appeals. Concurrently reviewed all medical records identified in the task order(s) to identify documentation deficiencies. For an inpatient stay, reviewed the provider documentation daily and recommended an addendum to the record if necessary. If it was determined, a provider’s documentation was not improving, recommended a corrective action plan to identify specific areas of improvement, a remediation plan that included a timeline in which to achieve positive results and a follow up plan and the corrective action plan approved prior to implementation. A summary of all providers placed on a corrective action was included in the monthly report of services rendered. Performed staff relief as a clinical charge nurse for various inpatient and outpatient facilities. Created and implemented corrective measures for clinical accuracy for providers as needed. Educated providers on clinical accuracy. Performed integrity revenue audits

02/2/2013--03/2015

Care National

HEDIS Nurse Auditor/Utilization Review Nurse

Performed chart reviews for various insurance companies in order to ensure compliance of both patients and providers as well as obtained proof of services performed and billing submitted. Performed revenue integrity audits monthly. Independently conducted audits of medical record documentation compared to patient charges on a concurrent and retrospective basis. Itemized claims while validating with medical records. Reported documentation deficiencies, billing errors, and trends to the appropriate department heads in writing or e-mail. Reviewed daily departmental charge reports. Investigated and resolved charging and coding questions raised by patient financial services and clinical personnel, including assessment of documentation to support charges, accuracy of services billed, edits, etc. Certified Coder. Worked in coordination with the revenue integrity coders and CDM department. Executed concurrent audits of claims to ensure the correctness of the financial record. Concurrently reviewed all medical records identified in the task order(s) to identify documentation deficiencies. For an inpatient stay, reviewed the provider documentation daily and recommended an addendum to the record if necessary. If it was determined, a provider’s documentation was not improving, recommended a corrective action plan to identify specific areas of improvement, a remediation plan that included a timeline in which to achieve positive results and a follow up plan and the corrective action plan approved prior to implementation. A summary of all providers placed on a corrective action was included in the monthly report of services rendered. documentation specialist Utilized ICD-9/CPT coding as well as HCPCS coding. Processed denials and appeals. Created and implemented corrective measures for clinical accuracy for providers as needed. Educated providers on clinical accuracy.

12/2012--03/2015

Contemporary Staffing Solutions

LPN Case Manager

Provided triage, verified coverage and preauthorized various procedures and services as well as provided educational teaching to patients. Performed clinical nursing in various clinics throughout the hospitals throughout Maryland, D.C., and Virginia.

05/2012--12/2012

CMS ProStaffing

LPN Utilization Review Nurse

Provided clinical care for disabled military veterans and performed utilization review. Administered medications, wound care, clinical nursing, preauthorized various services and procedures, performed discharge planning/care management.

11/2011--3/2012

R/O Resources

Utilization Review Nurse/Hospital Care Coordinator/Discharge Planner

Performed utilization review and preauthorized various services by using both Interqual and Milliman. Provided discharge planning and hospital care coordination for Medicaid managed care members. Utilized ICD-9/CPT coding as well as HCPCS coding. Audited clinical documentation for accuracy and improvement and processed denials as well as appeals. Created and implemented corrective measures for clinical accuracy for providers as needed. Educated providers on clinical accuracy.

01/2009--04/2012

Outcomes Health Solutions

HEDIS Nurse Auditor

Performed chart reviews for various insurance companies in order to ensure compliance of patients and providers, as well as obtained proof of services performed and billing submitted. Performed revenue integrity audits. Clinical documentation specialist. Independently conducted audits of medical record documentation compared to patient charges on a concurrent and retrospective basis. Itemized claims while validating with medical records. Reported documentation deficiencies, billing errors, and trends to the appropriate department heads in writing or e-mail and reviewed daily departmental charge reports. Investigated and resolved charging and coding questions raised by patient financial services and clinical personnel including assessment of documentation to support charges, accuracy of services billed, edits, etc. Certified CCS Coder. Worked in coordination with the revenue integrity coders and CDM department. Executed concurrent review and audits of claims to ensure the correctness of the financial record. Utilized ICD-9/CPT coding as well as HCPCS coding. Audited clinical documentation for accuracy and improvement and processed denials as well as appeals. Created and implemented corrective measures for clinical accuracy for providers as needed. Educated providers on clinical accuracy.

01/2009 - 01/2012

The Ravens Group

Assistant Project Manager/Lead LPN Nurse Manager

Provided leadership for all healthcare hospitality operations at Walter Reed Army Medical Center. Performed utilization/concurrent review. Utilized ICD-9/CPT coding as well as HCPCS coding. Provided medical billing. Ensured compliance with both military and hospital policy and standards. Coordinated and provided training for all operational staff. Provided constructive coaching and counseling to supervisory staff and team members when necessary. Ensured that all supervisory staff had tools necessary, to deliver service that exceeded expectations. Audited clinical documentation for accuracy. Ensured that all routine training was completed, performed revenue integrity audits and employee files were up to date. performed revenue integrity audits Completed regular reports and monthly audits as required in a timely manner and delivered them to all appropriate parties. Coordinated staffing needs, as required and schedules for all personnel.

08/2007-08/2008

Spectrum Healthcare Resources at Malcolm Grow Medical Center, Andrews Air Force Base, MD

Authorization Nurse

Preauthorized various services and healthcare for military dependents, retirees, as well as active duty personnel. These services included physical therapy, occupational therapy, durable medical equipment and surgical procedures. Performed utilization review. Utilized ICD-9/CPT coding as well as HCPCS coding. Certified CCS Coder.

07/2006-12/2006

Kelly Services at National Naval Medical Center Bethesda, MD

Deputy Comptroller Resources Manager

Assisted the deputy comptroller as needed. managing the deputy comptroller office, assisting the Budget and Fiscal Departments. Processed Third Party Collection claims and performed medical billing, preauthorization, coding and insurance verification. Utilized ICD-9/CPT coding as well as HCPCS coding. Processed retroactive claims and performed revenue integrity audits. Certified CCS coder. Provided chart and utilization review. Itemized claims, while validating with clinical documentation.

01/2005-07/2005

Health Net Federal Services at National Naval Medical Center Bethesda, MD

Utilization Nurse

Reviewed clinical and authorized appropriate care, by utilizing Milliman and Roberts and Interqual Guidelines. Resolved issues between providers and patients and reviewed claims. Processed retroactive claims. Preauthorized surgeries, medications, occupational and physical therapies, and specialty visits. Maintained clear and legible reports and referral document logs. Performed utilization reviews. Clinical documentation specialist. Educated providers and patients on referral guidelines and referral process and determined benefits. Processed denials and appeals.

11/2003 - 02/2004

VNA of Maryland

Clinical Coordinator

Coordinated and preauthorized appropriate staffing for homebound patients in need of clinical services. Maintained, updated, medical records and insurance information, and clinical reports. Ensured appropriate guidelines were maintained. Telephone triage, liaison for physicians and providers, as well as obtaining appropriate referrals and assessing the appropriateness for care by utilizing company and state guidelines through chart review and authorizing appropriate services as well as procedures. Validated clinical documentation for accuracy. Performed revenue integrity audits.

11/2002 - 11/2003

Mariner Healthcare Systems

Alzheimer’s Case Manager

Provided care management for individuals suffering from Alzheimer’s as well as Parkinson Disease

1/2002 - 11/2002

SRP, LLC Washington, DC

Case Manager

Obtained baseline health information about the child from an assessment questionnaire conducted with the member and family at an enrollment interview. The case manager utilized this to facilitate the development of a multidisciplinary written plan of treatment in collaboration with the member, family, PCP, and other appropriate professionals. The plan of treatment was developed within the first sixty days of coverage. Preauthorized appropriate services and procedures based on physician’s plan of care orders and clinical documentation.

3/1998 - 3/1999

Greensville Correctional Center Jarratt, VA

Infirmary/Correctional Nurse

Provided quality healthcare in the infirmary for maximum security inmates which included medication administration, intravenous therapy, phlebotomy, wound care and educational teaching. Utilized ICD-9/CPT coding and HCPCS coding.

2/1998 - 12/2001

Amerigroup Corporation Virginia Beach, VA

Medical Management Licensed Practical Nurse

Preauthorized healthcare and diagnostic testing for Medicaid HMO patients and provided nurse on call services/customer care, telephone triage, authorized healthcare and medications for Medicaid members. Medical billing and medical transcription were also included in my duties. Utilized ICD-9/CPT coding as well as HCPCS coding. Performed utilization management as well as concurrent review and clinical auditing for Medicaid members. Processed retroactive claims and validated clinical documentation for accuracy.

3/1997 - 2/1999

Correctional Medical Services Jarratt, VA

Infirmary Correctional Nurse

Provided total clinical care in the infirmary for inmates in a maximum security facility which included wound care, intravenous therapy, phlebotomy, medication administration, educational teaching, creating care plans and assisting the physicians as needed. Utilized ICD-9/CPT coding as well as HCPCS coding.

Duties also included chart reviews, medical billing and medical transcription and auditing clinical documentation for accuracy.

1/1997 - 9/2001

ATC Healthcare Norfolk, VA

Licensed Practical Nurse

Provided total clinical care for medical surgical patients which included wound care, intravenous therapy, phlebotomy, educational teaching, triage, wound care, creating care plans, and assisting the physicians as needed as well as medication administration. Duties included medical billing, chart review and medical transcription. Audited clinical documentation for accuracy. Utilized ICD-9/CPT coding as well as HCPCS coding.

10/1992 - 12/1997

Sentara Health System Norfolk, VA

Licensed Practical Nurse

Provided clinical nursing care for obstetrical and gynecological patients, as well as their newborns which included educational teaching, medication administration, triage, wound care, phlebotomy, intravenous therapy, telephone triage, medical billing, chart review and assisting the physicians as needed.

10/1992 - 1/1999

United States Army Reserves

Licensed Practical Nurse

Provided nursing care for critical care patients at Veteran's Hospital, which included telemetry monitoring, intravenous therapy, phlebotomy, wound care, educational teaching, creating care plans, and assisting the physicians as needed.

10/1992 - 8/1995

Pediatric Partnership

Pediatric Licensed Practical Nurse

Administered medications to pediatric patients, triage, intravenous therapy, phlebotomy, wound care, nurse on call/telephone triage, and assisted the physicians as needed.

MILITARY

1/1992-1/1999

US Army

Certification

Critical Care Unit LPN

06/1986-06/1988

US Navy

Certification

Security Force Member

06/1988-01/1992

US Navy Reserves

Security Force Member

EDUCATION

08/2015 08/2017

Liberty University

Bachelor's Degree

Theology/Biblical Studies

10/1992 10/1993

Career Development Center US-Virginia-Newport News

Maryland Licensed Practical Nursing License #LP36075

Washington DC Licensed Practical Nursing License # LPN1006293

02/2009

American Heart Association Adult/Child CPR/First-Aid Certification

SKILLS

Microsoft Word/Excel/PowerPoint

Centramax/Amysis

Microsoft Outlook Express/WordPerfect

Phlebotomy, Intravenous Therapy

Medical Billing/Medical Coding

Healthcare Management/Case Management/Utilization Review/Pre-Authorization

Third Party Collections/Chart Review

Revenue Integrity Auditor

Project Management/Clinical Management

Midas

Powerchart

Care Connect

MHC

References provided upon request.



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