Registered Nurse Medical
Resume:
Denise D. Virag, RN, BSN
Lower Burrell, PA 15068
PROFESSIONAL EXPERIENCE
Clinical Reviewer Medical Review Part A - Novitas Solutions, Inc. (formerly
known as Highmark Medicare Services) _October 29, 2012 - Present
. Analyze and reviews complex healthcare pre and post pay claims data
and appeals from a medical perspective.
. Conducts and renders a clinical decision concerning the validity of
health care claims and levels of payment based on the Center for
Medicare and Medicaid Services (CMS), medical necessity, utilization,
national and local policies, Social Security Act, and appropriateness
of care as well as accepted medical standards of practice.
. Initiates and conducts one: one regional educational calls involving
discussions with Healthcare leaders and CMS leaders in accordance with
Medicare Progressive Corrective Action.
. Works within multiple computer applications such as the Fiscal
Intermediary Standard System (FISS), Highview, InterQual, and Oracle
systems; Internet and Microsoft Windows applications.
. Meet workload expectations in a timely manner per CMS requirements.
. Excellent organizational, investigative, and analytical skills.
. Strong understanding of coding systems such as ICD-9, HCPC, CPT
medical codes.
. Excellent oral and written communication skills and the ability to
handle highly sensitive issues with the utmost professionalism and
diplomacy.
. Assumes the role of preceptor to assist and instruct new staff
members.
. Coordinates timely and accurate responses for all providers under
review.
. Works with informatics and other workgroups to obtain relevant
statistical analysis for reviews.
. Analyze and interprets requirements of the Social Security Act, Code
of Federal Regulations, and other program requirements.
Clinical Nurse II - West Penn Allegheny Health System, Pittsburgh, PA
Medical-Surgical Nursing/Obstetrics &
Gynecological Nursing
Western Pennsylvania Hospital _ August
1999 - March 2013
Allegheny Valley Hospital _ July 1990 - August 1999
. Responsible as charge nurse for overseeing patient care, staff
assignments, emergency response and management of patient crises.
. Displayed expert clinical skills within the unit to patients with
medical emergencies, trauma, surgical, and obstetrical interventions.
. Instructed educational classes to staff and revised policy &
procedures as a committee member.
. Experience with computer systems SUNRISE, CHAS, McKesson, and GE
Centricity software documentation programs.
. Exceptional capacity to multi-task, manage competing priorities with
ease while fostering delivery of direct patient care towards adult,
geriatric, and labor/post-partum/nursery patients.
. Contributed to strategic plans and initiatives to advance standards of
care excellence, improve patient outcomes and drive continuous
improvement.
. Gathered and analyzed clinical data for Highmark Perinatal Project
through the Western Pennsylvania Hospital Labor & Delivery Department.
Certified School Nurse Substitute - Burrell School District
Kiski Area
School District
December 2003-January 2013
Certified School Nurse - Pennsylvania Leadership Charter School,
Pittsburgh, PA 2008-
2009 School Year
. Maintained a comprehensive health record for each student including
immunizations, results of tests and screenings, and physical and
dental examinations.
. Interpreted the health needs of children, and assisted families with
community resources to meet their children's health needs.
. Administered medication to students as requested by parents or
physicians according to the medication guidelines.
. Collected health information and completed all data entry as requested
by the Department of Health and Department of Education.
EDUCATION
Slippery Rock University, Slippery Rock, PA
Professional Educator Certificate School Nurse K-12
December 2003
Penn State University, New Kensington, PA
Bachelor of Science in Nursing
May 1998
Citizens General Hospital School of Nursing, New Kensington, PA
Nursing Diploma
June 1990
CREDENTIALS & AWARDS
Sigma Theta Tau International Honor Society
Alpha Sigma Lambda Honor, Penn State
Penn State Alumni Association
Bell-Avon Alumni Association Scholarship Award
Registered Nurse License, State of Pennsylvania
CPR Certification
Professional References available upon request.
Contact this candidate