Videria Drayton Tarver RN, MSN, CCM

*** ***** ***** *****

North Augusta, SC 29841

adt3gy@r.postjobfree.com

706-***-****

Summary

A highly skilled and motivated masters-prepared registered nurse, with extensive experience in the managed care industry, which includes, utilization management, case management, clinical appeals and DRG validation appeals, clinical quality and auditing and coaching and training.

Professional Experience:

Clinical Programs Auditor- 2021- Present

Florida Blue a Guidewell Company/Remote

Responsibilities

oAudit (monthly) clinical and non- clinical staff cases (57 auditees)

oReal time auditing of NCQA /HMO Complex Case management cases

oCoaching clinical and non- clinical staff on audit errors

oBiweekly presentations for ongoing NCQA readiness

oPrepare monthly reports for teams (8)

oTrending/Reporting

Clinical Appeals Nurse (part-time)- 2021-2021

Responsibilities

oClinical denial reviews

oMedical Necessity reviews

oDRG Validation Audits

Clinical Denials Specialist-2021-2020-VBO

Responsibilities

oClinical denial reviews

oReview of Clinical Guidelines (MCG-InterQual)

oMedical Necessity reviews

oClaims review

Appeals Nurse Consultant-2018- 2020- Aetna/CVS

Responsibilities

oReview of Local and National Coverage Determination

oReview of Clinical Policies

oReview of Clinical Guidelines (MCG-InterQual)

oCase review and prep for medical director review

oCoding/Flash code

oDRG Re-Admission Reviews

2018-2018 -PGBA

Responsibilities

oMedical review

oHome Health reviews/OASIS reviews

oGuidelines review

oQuality measures

Clinical Auditor/ Appeals Nurse-2012- 2018- United Healthcare Clinical Services (Telecommuter)

Responsibilities

oPrior Authorization reviews

oCompliance Reviews

oClaims Reviews

oReport Compilation/ Preparation for Medical Director Review

oEnd-to End process review audit (Clinical Coverage Review)

oReview of medical records for physician review

oIdentify trends and areas of opportunity

oReview of Clinical Guidelines (MCG-InterQual)

oReview Standard Operating Procedures (SOPs) and Job Aids for adherence to state and federal criteria

Accomplishments

oSubject matter expert medical records (outreach project)

Telephonic Case Manager-2010- 2012- AWAC MD (InVentiv Medical Management)

Responsibilities

oCost Savings/ Targeted Populations

oHealth and wellness education

oMonthly reports with outcomes to insurers

oCare coordination

oClinical research

oClaims Review

oOriented new nurse case managers

oComprehensive written health assessments

Appeals Analyst-2004-2010 University Hospital Revenue Management Department

Responsibilities

oCoding Reviews/3M Encoder

oConcurrent and Defense Audits / Inpatient and Outpatient

oMicrosoft Excel, Microsoft Access, Microsoft Word, Power Point

oComplaints

oMedical Necessity/Medical and Surgical Reviews

oDaily review of department charges

oPrepared denials for Maximus

Accomplishments

oCost savings- Respiratory therapy ($30,000))

oCost savings surgery ($17,000)

oCost savings Interventional Radiology ($37,000)

oDefense audits (soft savings)

Chronic Disease Case Manager -2002-2004 Humana Military Healthcare Services

Responsibilities

oNegotiations, Cost Savings

oClient education

oHospice, Durable Medical Equipment

oCoordination and Utilization

oClaims Review

Ambulatory/Medical Surgical Nurse -2000-2002 Saratoga Medical Center, Inc

Responsibilities

oCare of pre and post surgical clients

oPre and post operative teaching

oAssessment and history completion

oLab draws/Testing

oCharge nurse

Hospital Bill Auditor-1994- 2002-Cost Management Systems

Responsibilities

oOn-site medical audits

oNegotiations

oUtilization Review

oCost savings

Operating Room Nurse -1998 -2000-Palmetto Richland

oSurgical Care of multitrauma clients

oCirculate major cases

oScrub minor cases

oRelief charge nurse

Operating Room nurse/Post anesthesia nurse-1997-1998- Aiken Regional Medical Centers

Responsibilities

oCirculate major cases

oScrub minor cases

oPost anesthesia care unit (PACU)

Nurse Consultant -1991-1994- Travelers Insurance

Responsibilities

oClaims Review for medical necessity

oDiscuss treatment regiments with policy holders/providers

oCase Management

oCost containment, reconsiderations

oMedical reviews

Critical care/Surgical nurse-1991-1991- Aiken Regional Medical Centers

Responsibilities

oCritical care/operating room nurse

oCirculate and scrub surgical cases

oQuality Reviews

oPre and post operative teaching

oCost savings

Oncology nurse/operating room nurse-1982-1987- University Hospital

Responsibilities

oCare of cancer clients

oChemotherapy administration

oCharge nurse

oCirculate major cases (including open heart)

oScrub minor cases

oQuality reviews

oPre and post operative teaching

Education/Credentials

2014-2015-Additional graduate Nursing courses completed (Maryville University)

2015- MCG Certification (Care Guidelines Specialist)

2011- Master of Science in Nursing at Grand Canyon University

2009-Bachelor of Science in Nursing- Excelsior College

2003- present- Certified Case Manager

1984-1982 University of South Carolina @ Aiken Associates Degree Nursing

*South Carolina Compact Nursing Licensure (included North Carolina)

Skills

oPresentation

oManaged care

oLeadership

oIndividual and Team Contributor

oLifelong learner

oProficiency in Microsoft products

oExcellent written/ communication skills

oMicrosoft Teams/Zoom/Google Meets

oOutcomes Management

oCritical thinking/problem-solving skills

oSubject matter expert (Clinical appeals, Case management)

o15 years of medical, surgical and critical care experience

References

*Upon Request

Community Service

oHealth ministry member

oEducate/coach diabetics and others with chronic diseases

oResource for managed -Medicare to community

Thank You

I appreciate the opportunity to submit my resume and credentials for review for a position in clinical quality. I aspire to improve the healthcare experience, cost of care and access, as well as improving processes and clinical quality measures. In addition, I enjoy supporting, working with, and empowering nurses, patients, and team members. In addition, I enjoy teaching and helping others with their health goals and needs. With more than thirty years of diverse experience, I would be pleased to discuss career options with your organization. I hope to hear from you soon and thank you in advance for any consideration.

Sincerely,

Videria Tarver MSN, RN, CCM

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