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Healthcare, Health insurance, teaching, medical sales, process improve

Location:
Wall Township, New Jersey, United States
Salary:
110000
Posted:
October 03, 2016

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Resume:

EMAIL: acwwaq@r.postjobfree.com

QUALIFICATIONS PROFILE

Detail-oriented and results-driven professional with broad-based experience in clinical setting as

well as in health insurance regulations and practices. Expert in utilization management claims

review, and provider audit. Equipped with strong work ethic to deliver the highest service quality

standards to meet client objectives and provide their needs.

CORE COMPETENCIES

Business Process Improvement

Vendor Training

Quality Assurance

Health Insurance Industry Regulations Provider Audit

Utilization Management

Telephonic Case Management

Health Promotion

RELEVANT EXPERIENCE

Confidential Newark, NJ

Registered Nurse Clinical Audit Analyst, Clinical Analysis Monitoring Unit Jan 2014–Present

- Serve as the liaison to Horizon Blue Cross Blue Shield Business Process Improvement Team

- Educate vendors on CAMU process to execute take-over of a high-volume account

- Provide expert oversight and quality assurance of vendor (Cotiviti) in joint project

- Spearhead new analyst training program and develop workflows for team members

- Formulate performance matrix for new hires which comprise of key milestones and skills

assessment, monitoring performance goals, and preparing status reports to the management

- Generate reviews and appeals for medical directors to identify medical necessity

- Examine and report quality assurance issues of providers and staff

- Collaborate with Special Investigation Unit in auditing fraudulent billing patterns of

providers

- Assume accountability of developing cases for presentation to the Board Of Medical

Examiners

- Earned recognition as the recipient of “Step it up” award for excellent performance and

professionalism

- Pioneered the development of new and efficient business processes while accomplishing

special projects for management, as needed

Registered Nurse Complex Case Manager (Fully Insured) Aug 2011–Jan 2014

- Took charge of telephonic care management of medically complex members which involved

health teaching and promotion as well as utilization review and benefit counseling

Visiting Nurse Association of Central Jersey Manasquan, NJ

Registered Nurse Complex Case Manager, Home Care Mar 2010–Dec 2011

- Served as the home care case manager for Center for Medicare and Medicaid Services (CMS)

home care company in Monmouth County

OTHER EXPERIENCE

Shore Rehabilitation Institute at Ocean Medical Center Brick, NJ

Certified Acute Rehabilitation Registered Nurse Mar 2006–Aug 2011

EDUCATION AND CREDENTIALS

Coursework toward Master of Science in Nursing Saint Peters University, Jersey City, NJ

Bachelor of Science in Nursing, Graduated cum laude Kean University, Union, NJ

Associate’s Degree in Nursing Ocean County College, Ocean Country, NJ

Practical Nursing Program Monmouth County Vocational School District, Freehold, NJ

Case Management Certification Rehabilitation Registered Nurse: State of New Jersey

Certified Registered Rehabilitation Nurse

ACTIVITIES

Horizon Blue Cross Blue Shield of New Jersey, Local Chapter Toastmasters Club: Founding Member

Sergeant at Arms

Juvenile Diabetes Research Foundation Animal Rescue Organizations

TECHNICAL ACUMEN

Microsoft Office Suite (Excel, Word, and PowerPoint) NASCO Share Point UCSW

Encoder Pro TPX PNO Clear Quest Impact Pro Lync Milliman Care Guidelines



Contact this candidate