Lucy Miller, RN, BS

Madison, WI

Summary:

•Extensive experience of working in appeals/ denials in healthcare environment.

•Act as a liaison between the state and members for member appeals-gather documentation related to the denied service, pass it along to the state.

•Write draft letters based on the state reviewer’s decision.

•Attend fair hearings on behalf of the Wisconsin Department of Health Services, present evidence, answer questions.

•Make decisions on provider appeals to the BadgerCare program to help determine whether the contested care can be covered and provide feedback to the Appeals department.

•Review HIV/AIDs and ventilator patients for possible capitation adjustments.

•Responsible medical necessity issues for other members of the department, including ombudsman.

•Take member and provider phone calls for questions related to HMO’s, exemptions, and appeals, to clarify coverage and rationale for approvals or denials.

•Conducted thorough utilization reviews and assessed medical necessity for wide range of procedures, surgeries, treatments, durable medical equipment (DME), medications, chemotherapy, and diagnostic tests.

Professional Experience:

CGS

10/2022 to 12/2022

Nurse Reviewer

•Review Medicare claims for potential fraud and abuse. Conducted thorough utilization reviews and assessed medical necessity for wide range of procedures, surgeries, treatments, durable medical equipment (DME), medications, chemotherapy, and diagnostic tests.

•Utilized up-to-date medical policies and guidelines to ascertain suitability of treatment, supported by evidence-based research.

•Act as a liaison between the state and members for member appeals-gather documentation related to the denied service, pass it along to the state.

•Orchestrated and maintained regular communication with medical directors, healthcare providers, patients, pharmaceutical and DME companies, as well as various departments and department director.

•Evaluated medical guidelines and benefit coverage to determine appropriateness of services.

•Take member and provider phone calls for questions related to HMO’s, exemptions, and appeals, to clarify coverage and rationale for approvals or denials.

•Orchestrated and maintained regular communication with medical directors, healthcare providers, patients, pharmaceutical and DME companies, as well as various departments and department director.

Noridian Health

1/2022 to 7/2022

Nurse Reviewer

•Review Medicare/Medicaid claims for potential fraud and abuse. Conducted thorough utilization reviews and assessed medical necessity for wide range of procedures, surgeries, treatments, durable medical equipment (DME), medications, chemotherapy, and diagnostic tests.

•Act as a liaison between the state and members for member appeals-gather documentation related to the denied service, pass it along to the state.

•Take member and provider phone calls for questions related to HMO’s, exemptions, and appeals, to clarify coverage and rationale for approvals or denials.

Logistics Health Inc.

2020 to 2021

Nurse Educator

•Train, provide updates and re-education for staff at remote COVID testing sites for which the company has contracts. Troubleshoot questions and concerns during phone calls from testing sites.

CoventBridge-Medicare/Medicaid Fraud and Abuse

12/2020 to 2/2021

Medicare Reviewer III 2020

•Review both paid and unpaid claims for Medicare and dual-eligible Medicare-Medicaid beneficiaries for evidence of fraud and abuse.

DXC Technology-BadgerCare Managed Care Program

2010 to 2019

Nurse Consultant

•Process/approve/deny exemption requests for BadgerCare HMO members seeking specialized treatment outside their HMO, so that they can receive care needed within a reasonable period.

•Act as a liaison between the state and members for member appeals-gather documentation related to the denied service, pass it along to the state.

•Write draft letters based on the state reviewer’s decision.

•Attend fair hearings on behalf of the Wisconsin Department of Health Services, present evidence, answer questions.

•Make decisions on provider appeals to the BadgerCare program to help determine whether the contested care can be covered and provide feedback to the Appeals department.

•Review HIV/AIDs and ventilator patients for possible capitation adjustments.

•Responsible medical necessity issues for other members of the department, including ombudsman.

•Take member and provider phone calls for questions related to HMO’s, exemptions, and appeals, to clarify coverage and rationale for approvals or denials.

•Perform review of long-term care cases to determine if they meet state criteria for coverage, using the MDS or chart documentation provided by the facility.

Care Wisconsin

2009 to 2010

Case Manager

•Manage the care for Frail Elderly and Physically Disabled members of the Care Wisconsin organization, including routine and acute visits to assess the member’s condition, coordinating receiving DME/medical supplies for treatment of acute and ongoing conditions.

•Attend member doctor visits and provide support and clarification of new or ongoing conditions, so that they can remain out of nursing homes and remain in their own homes safely.

Wisconsin Physicians Service

Tricare Division

1990 to 2009

Senior Review Analyst

•Trained utilization review staff on new/updated Tricare policy.

•Audited utilization unit staff and unit leaders monthly and provide training to remediate any deficiencies.

•Write or update unit procedure guidelines when Tricare policy was initiated or changed.

•Review complex medical cases, such as long-term care, transplants, dental, cosmetic/reconstructive surgery and determine whether policy criteria are met for payment utilizing InterQual criteria and Tricare policies.

•Refer cases to the Medical Advisor and process them when returned. Communicate with patients and providers regarding claims and documentation needed, to ensure that appropriate care is covered.

•Case manager for the Tricare Cancer Clinical Research program-review cases for Tricare patients to participate in approved cancer clinical research programs; produce authorizations for these trial participants and follow up the patients’ participation.

•Participate in policy review and system update discussions, policy implementations.

Registered Nurse, Staff Nurse

Hospital and outpatient care in Med/Surg, L&D, OB and Dialysis

Other Training & Experience:

InterQual training

ISO certification process

CPT, ICD9, ICD10, HCPCS

Microsoft Word, Excel, PowerPoint, Familiar with PC, Macintosh, & mainframe basic computer operations

Education:

University of Hawaii, Manoa Campus, Honolulu, Hi. Associate of Science Degree in Nursing

University of Wisconsin, Madison, Wi. -Bachelor of Science Degree in Textile Design

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