Lisa A. Hamilton

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

Round Rock, TX 78664

254-***-****

ad3cxa@r.postjobfree.com

SUMMARY:

An experienced and highly skilled Registered Nurse (RN) with a rich background in Case Management, actively seeking a remote position. Recognized professionally for analytical thinking, I bring expertise in continuous assessment and clinical oversight. As a self-motivated team player, I showcase exemplary clinical skills, emphasizing attention to detail and a proactive approach to resolving issues promptly and efficiently. I maintain composure in stressful environments, boasting a proven record of keeping challenging situations calm and under control.

EXPERIENCE:

Parallon HCA Healthcare, Nashville, Tennessee

June 2023 – Present

Prebill Denials Nurse, Registered Nurse

Working post discharge, prebill accounts efficiently and effectively on a daily basis to resolve accounts with “no auth numbers, ALOS vs. authorized days or other discrepancies.

Evaluating clinical documentation on multiple patient accounts and escalate issues through the established channels.

Performing accurate and timely documentation of all review activities based on policy and procedure.

Demonstrating working knowledge of managed care agreements based on available resources which may include and not be limited to payer UM Manual, policy and procedure, facility contract information.

Assess CPT code(s) for outpatient accounts that require authorization when accounts have not been coded.

Demonstrating knowledge of regulatory requirements, Ethics and Compliance policies, and quality initiatives; monitors self-compliance and implements process changes to ensure compliance to such regulations and quality initiatives.

Communicating with third party payors to resolve discrepancies prior to billing.

Accurately and concisely documents all communications and action taken on the account in accordance with policies and procedures.

Seeking assistance from immediate supervisor when in situations which are unclear or

ambiguous

Contacting facilities, physicians’ offices and/or insurance companies to resolve denials/appeals if needed.

Experience working across multiple sectors within the healthcare industry including acute care, informatics, healthcare project management, case management and utilization management, as well as clinical training.

Providing oversight and direction for acute care specialty hospital Case Management

Department.

Managing Acute Care Preauthorization for SNF, IRF, and LTAC levels of care. South Austin Medical Center, Austin, Texas

May 2019 – Present

Utilization Review, Registered Nurse, Observation-Case Manager

Manage and streamline

Observation work lists of up to 50 patients at a time by efficiently prioritizing and reviewing patients in observation longer than 24 hours.

Perform initial, concurrent, and retrospective reviews utilizing evidence-based criteria

(InterQual) and patient’s clinical through electronic medical records for appropriate bedding status.

Collaborated cases with physicians when patients met or did not meet inpatient criteria and need for upgrading or downgrading status.

Coordinate with the Interdisciplinary Team (IDT) requesting escalation for referrals, procedures, monitoring results, and evaluations to facilitate a successful care transition.

Monitor OR CPT and Authorization Tracker for same-day surgery scheduling, appropriate bedding status per prior authorization, and MCR Part A inpatient-only list.

Facilitate condition code 44 when MCR patients did not meet admission criteria for inpatient admission.

Collaborated with attending physicians regarding CMS two-midnight rule for Medicare Part A patients in Observation status.

Make recommendations regarding the appropriateness of care for identified diagnoses based on theresearch results for those conditions.

Providing oversight of process improvement in transitions of care for our patients to ensure that patients were maintained at their long term acute care expected length of stay and assist case manager with barriers that developed during a patient's stay.

Facilitate education and lead twenty-four RN/SW Case Managers in acute care hospital facility.

Responsible for building relationships with Acute Care facilities and community referral sources to assist with expanding PIPS services.

Piedmont HealthCare, Atlanta, Georgia

January 2018 – January 2019

Utilization Review, Registered Nurse (100 % Remote)

Conducted initial reviews on all Observation patients with greater than 24 hours of Observation status.

Utilized evidence-based criteria and patient's clinical electronic medical records for appropriate bedding status. (InterQual- MCR/MCG-Unfunded, Commercial, Managed Care and Medicaid) Coordination with the interdisciplinary team escalating referrals, procedures, monitoring results, and evaluations to facilitate a successful care transition.

Communicated with physicians when patients met or did not meet inpatient criteria and needed upgrading or downgrading status.

Monitored patients ensuring progression in their plan of care as well as meeting medical necessity for continued stay.

Performed concurrent reviews utilizing evidence-based criteria for inpatients who continued stay reviews.

Ensured that the patient's payer had clinical information to authorize the continued hospital stays, days, and services provided.

Maintained effective communication with attending physicians. Baylor Scott & White Health, Temple, Texas

May 2015 – December 2017

Utilization Review, Registered Nurse (100 % Remote)

Applied clinical acumen when focusing on prior authorization and concurrent review for all outpatient and inpatient clinically complex cases.

Reviewed member and provider request for medical necessity criteria for coverage based on a review of the member's benefit certificate/document, applicable medical policies, procedures, evidence of coverage, a summary of plan details, and National and Local Coverage Determination.

Drafted approval and denial letters based on case determinations.

Forwarded cases that did not meet medical necessity criteria to the medical director for review.

Completed administrative denials on services excluded by the member's benefit certificate/document and maintained compliance with events.

Guided members and providers with the referral and authorization process, benefits interpretation, and other utilization issues.

Called hospitals and case managers/utilization review departments to request clinical, inform the authorized days, and schedule peer-to-peer discussions between the medical director and attending physician.

St Catherine’s Nursing Home, Albuquerque, New Mexico December 2014 – May 2015

Resident assessment coordinator, Registered Nurse

Coordinated, supervised, and evaluated the care of patients. Epic Health Services, Houston, Texas

June 2011 – November 2014

Pediatric Registered Nurse

Private duty Registered Nurse managing home patient care. Sol Amor Hospice, Albuquerque, New Mexico

September 2004 – February 2011

Director of Clinical Services

Responsible for the overall direction of Hospice Clinical Services. EDUCATION:

Trinidad State Jr College, Alamosa, CO

Associates Degree in Nursing

1990 – 1992

Adams State University, Alamosa, CO

Prerequisites for Nursing

1988 – 1990

San Luis Valley Vocational, Alamosa, CO

Licensed Practical Nurse

1987 – 1988

CERTIFICATIONS:

Resident Assessment Coordinator – Certified, Basic Life Support (BLS), Ventilator & Tracheostomy, Private Duty Nursing

SKILLS & ABILITIES:

Utilization Review, Analysis, Health Insurance, Claims Processing & Compliance, Communication, Time Management, Appeals & Denials, Medicaid/Medicare Regulations, Electronic Medical Records (EMR), Electronic Health Records (EHR) Software Expertise:

Midas, Meditech, OnBase, Avaya, AVAILITY, InterQual, Artiva, Epic, MCG, OnBase, NaviHealth, MACE Medical, Office, Zoom, WebEx)

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