LAURA M. CROWDER
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.
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
ALZHEIMER CENTER, Denver, CO
DR. SOLOMAN FAMILY PRACTICE, Denver, CO
RN Practice Manager
UNIV. DENVER MD RESIDENCY PROGRAM, Denver, CO
ST. PAUL NURSING HOME, Denver, CO
Assistant Director of Nursing
ROANOKE MEMORIAL HOSPITAL, Roanoke, VA
CCU/ICU Charge RN
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