Kathleen Grinberg-Funes

518-***-**** ad4rhe@r.postjobfree.com

PROFESSIONAL SUMMARY

Track and report all appeals activities to local, state and regional enterprises on a monthly and year basis Instruct and supervise both professional and nonprofessional staff in completion of all appeals activities Liaison with Medical Staff directors in review of appeal activities Construct and participate in all state appeals for members EXPERIENCE

Clinical Care Reviewer Regional Appeals Unit, Ameri/Health Caritas Charleston, SC

- Analysis of provider disputes and provider/member appeals for denied inpatient, outpatient and ancillary services based on accuracy of coding, lack of medical necessity or inappropriate place of service.

- Verification of claims appropriateness based on provider contractual agreements, fee schedules and Medicaid regulations.

- Assess for provider delivery trends inconsistent with program integrity with extensive report preparation summarizing findings.

- Identification and reporting of potential sentinel events, quality of care concerns and hospital acquired. Clinical Care Reviewer Medical Loss Unit, Ameri/Health Caritas Charleston, SC

- Identifies patterns of provider utilization and/or patient outcome trends that require in-depth analysis.

- Develops study designs for claims project analysis to include applicable claims methodology, current Federal, State & Local regulations, and evidenced based practice guidelines.

- Analyzing complex medical record data, providing comparison to the accuracy of coding practices, evaluating the medical necessity of care, potential quality of care deviations and appropriate place of service.

- Applies coding applications and APR-DRG grouper methodologies to assess individual and group provider billing practices.

- Recommends procedures to evaluate and valid claims accuracy and patterns of resource utilization.

- Reviews specific claim types and provider practice patterns to recover monies and assess potential fraud and abuse for report to the Corporate Special Investigation unit.

- Extensive report writing summarizing project outcomes and recommendations for further analysis or quality initiatives based on audit outcomes.

Quality Improvement Specialist Medical Loss Unit, Ameri/Health Caritas Charleston, SC

- Analysis of HEDIS and CAHPS results and development of strategies to integrate results with QI departmental and Plan goals.

- Collaboration with Network Management and Network Operations departments to facilitate barrier analysis and develop QI activities to improve service processes, efficiencies, clinical outcomes and the provision of provider education.

- Coordination of HEDIS medical record review processes and Nursing inter-rater reliability review audits.

- Development, implementation and maintenance of QI policies and procedures.

- Participates in organizational efforts in ongoing Quality Improvement processes to ensure compliance with State, Federal regulatory and accrediting (NCQA) standard requirements.

- Lead multi-disciplinary task force to identify opportunities for improvement of system processes, member compliance and clinical outcomes.

Quality Assurance Manager Gentiva Home Health

Charleston, SC

- Analysis of patient record case-mix weights to assess appropriate utilization of staff and equipment resources with respect to budgetary goals.

- Implement staff education programs to assure adherence to Medicare and Medicaid regulations, with emphasis on reduction of risk and medical/clinical errors.

- Collaboration with management team to assess real and potential loss of revenue, patterns of utilization needs for revision in policy and practice.

- Coding of all out-patient home health medical records in accordance with ICD guidelines. EDUCATION

- Bachelor of Science in Nursing

University of Toledo

ADDITIONAL ACTIVITIES

- Registered Nurse, Toledo Hospital School of Nursing

- South Carolina Registered Nursing, License # 212602

- Member of AAPC; CPC