Managed Care Acute
Resume:
Katherine E. Gittrich, LPN, CMCN
309-***-**** • ******@*****.***
Professional Summary
Experienced Quality Management Nurse with 23 years experience in managed care review and compliance, including commercial and Medicare/Medicaid. Core Qualifications
● Outstanding communication skills with extensive experience working with medical directors and all members of the medical team
● Extensive familiarity with nursing procedures, managed care principles, medical terminology, and knowledge of CMS requirements
● Consistently exceeds company performance metrics, including timelines according to Medicare and NCQA
● Extensive computer experience with MS Office Suite applications and proven record of navigating and efficiently learning new applications and systems Experience
Humana, Compliance Nurse, 2010-2023
• Reviewed cases for skilled nursing facilities, inpatient rehab and long-term acute care hospitals in accordance with Medicare/Medicaid guidelines
• Compliance review of approval letters, denial letters
• Consistently a top producer, with extensive experience writing Detailed Explanation of Non-Coverage (DENC) and Detailed Notice of Discharge
(DND) letters
Kindred Long Term Acute Care, Case Manager, 2009-2010
• Case management specializing in complex discharges
• Commercial and Medicare choice reviews with managed care companies Humana, Utilization Review Nurse, 2008- 2009
• Authorized outpatient procedures, referrals, durable medical equipment, network authorizations for commercial clients.
OSF HealthPlans, 1999-2008
● Consistent top performer responsible for pre-service, retro claim reviews, outpatient and inpatient surgery, CT and MRI prior authorization and Durable Medical Equipment.
● Responsible for in-network and out-of-network referrals and procedures.
● Completed internal audits for NCQA certification Education and Certifications
Certified Managed Care Nurse CMCN
Licensed Practical Nurse active 043.078712
Associates Degree – Nursing, 1995, Illinois Central College, East Peoria, IL
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