Managed Care Nurse

Paula Jean Martel, RN/BSN/CCM/CBCS

PROFESSIONAL PROFILE

Highly motivated Registered Nurse (RN) with extensive clinical experience and superior analytical skills with a special interest in Managed Care environments. In-depth understanding of payer specific medical policies, healthcare status and national guidelines. Adept at identifying services rendered in validating appropriate levels of care and addressing issues related to appeals which require clinical input or interpretation. Oversee and monitor documentation and charting requirements that support services provided to meet billing requirements including state specific requirements for supportive documentation. Retired veteran of United States Air Force, having served as a Medical Service Specialist and Clinical Nurse.

CORE COMPETENCIES

Review and Analysis of Denials Writing Professional Appeal Letters Quality Assurance Review Submission and Follow-up Reporting and Education Compliance with Federal, State and Third-party Payers Utilization Management Internal and External Billing Audits

PROFESSIONAL EXPERIENCE

Vidhwan Inc DBA e-Solutions, Inc, San Jose, CA 07/06/2021 – 09/08/2021

Remote Denial & Appeals Review RN

Provided support to, and functioned as, initial data intake team by reviewing and processing provider appeals for denied payment due to not meeting medical necessity criteria.

Requested Waiver of Liability and Appointment of Representation forms, from non-participating providers, if needed.

Reviewed all imported documents, to ensure completeness of appeal documents, prior to assigning to appropriate departments per companies’ policy and procedures.

Jupiter Medical Center Jupiter, FL 05/2012 - 06/2020

Clinical RAC Coordinator 05/2012 - 06/2020

Wrote clinical appeals for medical necessity denials, level of care denials, and lack of clinical documentation denials issued by Commercial insurance companies and Medicare

Performed electronic medical record research for denials as well as audits

Participated in billing audits with both internal and external entities

Provided clinical support to multiple non-clinical financial and health information departments within the acute hospital setting

Specialty Leader Case Manager 02/2012 - 12/2012

Assessed, planned, implemented, coordinated, monitored and evaluated options and services to meet a patient's need

Used available resources to assist in achieving an effective discharge plan while promoting quality health care with cost effective outcomes.

Coordinated and completed utilization management activities

Assured compliance with federal, state and third-party payers

Participated in performance improvement initiatives related to the management of patient care.

Fallon Community Health Plan Worcester, MA 2003 - 2011

Nurse Team Leader

Used a multidisciplinary approach to organize, coordinate, monitor, evaluate and modify plans of care, focusing on selected complex medical and psychosocial needs of health plan members and their families.

Responsible for developing comprehensive care plans for high-risk members to improve functional status and prevent hospitalization

Supervised the process of data entry into the appropriate data bases/applications

Assisted in the daily oversight of the operational processes within the Case Management Department

Oriented and trained team members at time of hire and during all departmental changes to workflow processes.

Responsible for creation and implementation of written policies and procedures within the Case Management Department

CIGNA HealthCare of Massachusetts 2000 - 2003

Patient Care Facilitator/Utilization Management

Applied professional clinical skills and expertise in conjunction with medical guidelines, member eligibility and benefit coverage information in the review of prior authorization requests to ensure high-quality, cost-effective care.

Managed clinical aspects of member appeals.

Processed medical claims for medical necessity reviews using InterQual criteria.

First Allmerica Financial Life Insurance Co 1999 - 2000

Nurse Case Manager/Utilization Management

Visiting Nurse Association of Central Mass, Inc 1990 - 1999

Community Health Staff Nurse

EDUCATION

Worcester Hahnemann Hospital School of Nursing Worcester, MA

Degree in Nursing

Fitchburg State University Fitchburg, MA

Bachelor of Science in Nursing (BSN)

PROFESSIONAL TRAINING

University of Phoenix (on-line) 2011

Healthcare Informatics Program

Broward College (on-line) 2016

Legal Nurse Consultant Program

CERTIFICATION

Ashworth College (on-line) 2020

Certified Medical Billing and Coding Specialist

Commission for Case Manager 1999

Certified Case Manager

MILITARY

United States Air Force 1980 - 1984

Medical Service Specialist

United States Air Force Reserves 1985 – 1999

Registered Nurse

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