Quality Manager Medical Billing
Resume:
DARLENE CUCINOTTA
Clermont, FL 34711
*******@*****.***
OVERVIEW:
Skilled Licensed Practical Nurse with strong quality improvement
background, seeking to leverage medical skills and proven interpersonal
strengths with a progressive, quality-oriented organization. Areas of
strength include:
- Quality Improvement - NCQA
- PCMH - HEDIS
- JCAHO Survey - DHMH
- Infection Control - Microsoft Office
- Policy Development - Medical Billing
- Cost Containment - Team Player
- Organizational Skills - Communication Skills
- Complaints, Grievances - Sentinel Events
and Appeals
EDUCATION:
Schuylkill County AVTS, Licensed Practical Nursing Program, Marlin, PA
College of Southern Maryland, LaPlata, MD
College Network, Indianapolis, IN
EXPERIENCE:
Caregiver for a Lymphoma Patient 2017-2022
Providing all aspects of nursing care for this patient.
Clinical Review Specialist/Appeals & Grievance Manager, Trusted
Health Plan, Washington, DC 2013-2017
THP is a minority-owned MCO, with approximately 28,000 members.
Initially starting out in the Utilization Management Department as a
Case Manager in October 2013, I was promoted to the position of Clinical
Quality Manager within two months. I supervised two employees and
oversaw the complaints, grievances, appeal, and sentinel events, assuring
compliance with DHCF regulation. I created an appeals and grievance
process for THP. I was a member of the Quality Executive Committee,
Grievance & Appeals Committee and Risk Management Committee. I took
a position in the Operations Department in 2015 as the Clinical Review
Specialist, where I performed clinical review, utilizing InterQual criteria,
to assure that admissions met medical necessity criteria. I also completed
review of outstanding authorizations in order to facilitate proper claims
payment(s).
Page 2
Caregiver, Leonardtown, MD 2011-2013
Provided all aspects of nursing care to an Alzheimer’s patient.
Quality Improvement Specialist, Unity Health Care, 2009-2011
Washington, DC
Completed HEDIS, UDS and COE audits with data entry into Excel
spreadsheets; Lead on the Chronic Care Initiative in conjunction with
DC DOH and nine other teams throughout the District. Focus was on
successful transition for our chronic care patient’s post-hospital
discharge back to their PCMH within five to seven days; Established
an infection control program for UHC including all policies and procedures
for the Infection Prevention and Control Committee. Organized monthly
committee meetings. Member of APIC national and local chapters. Part
of the training team for implementation of EClinicalWorks EMR.
Addictions Staff Nurse, Chesapeake Education, LLC 2005-2013
Anchor or Walden Sierra, Charlotte Hall, MD
Admitted clients who are addicted to drugs/ETOH for detox and
residential treatment. Medication management for all clients,
including half-way house clients. Provided client education on
smoking cessation, nutrition, STI’s/STD’s. Discharge of clients from
Anchor. Worked on a part-time basis during this time period.
Claims Director/Project Coordinator, Seafarers 1993-2005
Officers and Employees Benefits Plan, Camp Springs, MD
Supervision of forty-one employees with complete oversight of
the Claims Department. Implemented a cost-containment program
for the union. Assured proper adjudication of all claims. Department
processed approximately 162,500 claims per year. Proficient on
TriZeto Claimfacts system. From 1998-2005, I was responsible for
auditing of all hospital bills over $20,000.00. This involved negotiations
with providers of service throughout the United States. Additional
duties included operation of a Special Investigation Unit for provider
fraud cases. I worked closely with the FBI and DOJ on a large provider
fraud case in California.
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