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Nurse Manager

Location:
Louisville, KY
Salary:
85,000
Posted:
September 29, 2019

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Resume:

LAURA M. CROWDER

Louisville, KY ***** adag7b@r.postjobfree.com 502-***-****

NURSE MANAGER

Nurse Manager with extensive experience in prior authorization UM and financial CM. Comprehensive knowledge of claims and correct billing practices for all payers. Diverse background with ICD-10, CPT and HCPCS coding.

PROFESSIONAL EXPERIENCE

HUMANA, Louisville, KY 2019

Senior Payment Integrity Professional

Team Lead for the Observation Team

Research complex issues involving policy interpretation, working with legal and compliance based on clinical/coding issues

Investigate claims/audits regarding escalated issues or questions about criteria requirements

Review new hire cases and train new team members

Research escalated issues/complaints/suits/requests from upper leadership related to the team

Assist with questions or other technical problems that arise throughout daily operations

AETNA BETTER HEALTH OF KENTUCKY, Louisville, KY 2011 - 2018

Health Service Manager (2016 – 2018)

Responsible for identifying and correcting claims system issues, educating providers on correct billing processes, recouping overpayment. Acted as liaison between Health Services (Case Management and UM) and Operations Management (finance, provider relations, claims, appeals and contracting).

Attended State Medicaid Advisory Council meetings addressing dental, vision, physical/speech/occupational therapies, DME, home health and hospital, to resolve claims, PA, other clinical issues

Worked with Provider Relations Department to resolve claim issues

Strong ability to identify large cost savings (up to $300K) through audits

Prior Authorization Manager (2015 - 2016)

Developed and implemented the Prior Authorization Department: human resource management for 50+ employees and budget.

Concurrent Review Supervisor (2013 - 2015)

Human resource management and budget forecasting for 20+ employees, including Work From Home.

Monthly QA audits to ensure NCQA standards

Managed high dollar inpatient stays, provided insight on forecasting on estimated future payments

Case Manager (2011 - 2013)

Complex Case Management including telephonic assessment, care plan development and execution for 50-60 Medicaid members.

Responsible for high dollar infusion authorizations, working with providers and members to ensure timely, cost efficient infusions

WALGREENS INFUSION PHARMACY, Louisville, KY 2003 – 2011

Manager Pharmacy Intake

Responsible for 8+ staff, human resource management and budget; obtaining pharmaceutical and nursing prior authorizations from insurers for adult and pediatric nursing and infusion needs for all counties in Kentucky.

Assisted with negotiation on new provider contracts

Supervisor Financial Case Managers/Express Scripts

Responsible for the National Contract Team, supervising 17+ Financial Case Managers, Billers and Claims Specialists; human resource management and budget.

Staff RN Financial Case Manager/SpectraCare

Responsible for Home Health, DME, Infusion prior authorizations, working with providers and members to ensure necessary care was received.

Provided members with the financial obligation they would owe their insurer

Worked with billing, claims and contracting departments to ensure billing accuracy

ADDITIONAL PROFESSIONAL EXPERIENCE

BAPTIST HOSPITAL NORTHEAST, La Grange, KY

Director Medical/Surgical, Pediatric, Telemetry Units

Responsible for 80+ employees, all aspects human resource management and budget.

Passed 3-year JCAHO audit with no recommendations

Vendor review and implementation of new telemetry system

Responsible for adequate daily staffing ratios for the entire hospital

HUMANA, Kansas City, KS

Triage RN

ALZHEIMER CENTER, Denver, CO

Nursing Supervisor

DR. SOLOMAN FAMILY PRACTICE, Denver, CO

RN Practice Manager

UNIV. DENVER MD RESIDENCY PROGRAM, Denver, CO

Clinical Supervisor

ST. PAUL NURSING HOME, Denver, CO

Assistant Director of Nursing

ROANOKE MEMORIAL HOSPITAL, Roanoke, VA

CCU/ICU Charge RN

EDUCATION/LICENSES/CERTIFICATIONS

B.S.N. Lynchburg College, Lynchburg (Dean’s Honor List)

Registered Professional Nurse: Kentucky

Certified Professional Coder, MD curriculum classes

Technical skills: QNXT, IDX, InterQual, Milliman, Excel, Word, Outlook



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