Nurse Consultant Medical Review

CYRILLIA L. ANDERSON, RN, BSN

**** ***** ****** ****** ****************@******.*** M: 937-***-****

Cincinnati, OH 45237

QUALIFICATIONS

I’m the candidate you’re looking for! 25 years of conducting clinical reviews/utilization reviews/case management of medical records for fraud, mass tort, legal/subrogation, payment integrity claims reviews for data analysis and IT/Configuration/Coding upgrades Extensive knowledge of CMS Guidelines, medical terminology, ICD-9-CM, ICD-10-CM, HCPCS, CPT Coding as RN Domain Expert to the Coding Team. Refer to Caresource Inc. experience below. Proficiency with Facets Claims system knowledge, Claims related applications and software, Microsoft Office applications and Excel

Ability to identify and recommend process improvements utilizing leadership and communication skills when working with a multidisciplinary team and medical director

PROFESSIONAL EXPERIENCE

Incept Data Solutions, Inc, Dulles, VA October 2021-March 2022

Subcontractor RN Medical Review

Genesis Healthcare, Dunbar, WV October 2020 – October 2021

RN Nurse CNA Instructor: Long Term Care/Rehabilitation COVID Screener/Tester (POC/PCR)

Responsible for overseeing the CNA assessment programs, planning, implementation and evaluation of the

certified nursing assistant training at the long term care nursing centers and rehabilitation

Responsible for assuring regulatory compliance with state and federal guidelines and adherence to the philosophy and mission of Genesis Healthcare. Responsible for performing TST (Tuberculin Skin Test) for students and/or staff as required by state law and in accordance with company policy COVID-19: Successfully completed Clinical Competency Validation for testing and screening of staff and/or long term residents/new admissions by collecting specimens utilizing appropriate PPE per transmission-based precautions and requirements (e.g. gowns, gloves, face masks, N95 approved KN95 face shield and goggles. Responsible for performing NP (Nasopharyngeal), OP (Oropharyngeal), NMT (Nasal Mid-Turbinate) and AN (Anterior Nares) Specimens

CareSource, Dayton, OH March 2011 – August 2020

RN Medical Review Specialist, Legal/Claims COB/Payment Integrity Responsible for auditing and review of CMS Guidelines and directives in reviewing ODJFS (Ohio Department of Job and Family Services) and multi-state claims reviews by applying both Medicaid and Medicare guidelines as indicated

Medicaid Consent Forms and clinical documentation to ensure compliance with Federal and State requirements and established business standards. Responsible for evaluating and determining that services meet medical necessity, appropriate levels of care as well as site of service

Responsible for reviewing COB Legal and Subrogation Claims via excel to determine redaction of medical documentation in accordance with HIPAA and State Privacy Laws applying ICD-9, ICD-10. CPT, HCPCS and Diagnosis Code knowledge and expertise in reviewing cases. Responsible in the role of liaison and matrix team member/RN Legal Subrogation Nurse Consultant with the Legal and The Coding Team, Configuration Departments, Grievance and Appeals Department and State Complaints performing case reviews via Excel / Electronic Health Information.Training and Education of claims staff in ODJFS/KY Consent Form review processes. Special Projects for Operational Excellence Department, Grievance and Appeals Department and support to other departments throughout CareSource

Gentiva Home Health, Beckley, WV December 2008 – December 2010 Amedisys Home Health, New Orleans, LA RN Manager of Clinical Practice

Responsible for managing home health staff and scheduling Home Health staffing visits Responsible for ensuring that all compliance with Federal and State requirements and established business Standards while implementing Medicare criteria and ICD-9, HCPCS, Diagnosis codes and CPT correct coding expertise in preparing OASIS documentation for re-certifications of patients. Responsible for evaluating and determining that services meet medical necessity and appropriate levels of care and case management

St. Margaret Hall Nursing and Rehab Facility, Cincinnati, OH September 2004 - December 2008 RN Supervisor

Responsible for managing nursing home and therapy staff and scheduling care initiatives Problem-solving, conflict resolution, mentoring, teaching and support to staff and families

mentoring, teaching and support to staff and families

Responsible for ensuring that all compliance with Federal and State requirements and established long term care standards. Responsible for evaluating and determining that services meet medical necessity and appropriate levels of care

AvatarComp Inc., Cincinnati, OH May 2001 - September 2004 Garden Park

Nursing and Rehab Facility, Cincinnati, OH

RN Case Manager Workman’s Comp/Weekend Staff Nurse

Responsible for case management/coordination of care for Workman’s Compensation patients Responsible for ensuring that all compliance with Federal, BWC (Bureau of Workman’s Compensation) State requirements and established business standards Responsible for evaluating and determining that services meet medical necessity and appropriate levels of Care while applying

CMS Guidelines and Directives Responsible for managing physicians visits and therapy and scheduling care initiatives Responsible for managing nursing home and therapy staff and scheduling care initiatives

Community Mutual/Anthem Blue Cross/Blue Shield, Cincinnati, OH April 1987 - May 2001

RN Manager Claims Unit

RN Senior Medical Analyst

E.L.R.O.I. Project Domain Expert Clinical Review of Medical Records RN Medical Review Specialist

Successfully managed the restructuring of 4 separate medical review areas into 1 by creating staffing models, streamlining workflows, creating more consistent decision-making criteria and increasing team morale. Key member of crossfunctional/marketing/special project team titled E.L.R.O.I. (Expert Level Review of Information Team) responsible for the automation of the medical review processes, review of claims whose efforts generated a savings of $6.5 M by reorganizing four departments into one department (A.T.M.: Automated Transaction Management Unit) and working directly with the IT Department utilizing Decision-Tree Applications and the creation of system icons to enhance daily workflow processes by working directly with the RN Medical Review Department Staff.

Responsible in role of liaison/RN Domain Expert between Vice President of Clinical Affairs and The E.L.R.O.I Team utilizing CPT, HCPCS, Diagnosis Codes in conjunction with CMS Guidelines and Criteria Recruited to evaluate the issue of stress in the workplace resulting in the creation and implementation of an

“SOS” Stress Management Seminar which included 350 staff attendees, extremely positive feedback and a positive Great Place To Work Survey rating

Community Mutual Blue Cross and Blue Shield YMCA Black Achievers Award Recipient 1990 and Tri-Health Nominee for Woman of the Year 1992

1981-1987 ADN RN

Alaska Acres Nursing Home and Rehab Center August 1986 - March 1987

3584 Alaska Avenue, Cincinnati, OH

RN Staff Nurse/MDS

National Healthcare Review, Inc. (Cedars-Sinai) November 1985 - July 1986

22144 Clarendon Street, Woodland Hills, California

RN Audit Utilization

OH-9 Beckley-Raleigh Home Health/Public Health Dept. November 1984 - October 1985

1602 Harper Road, Beckley, WV

RN Home Health Nurse/Nurse Aide Supervisor

Jefferson Methodist Hospital June 1983 - October 1984

2301 South Broad Street, Philadelphia, PA

RN Staff Nurse Labor and Delivery/Scrub Nurse

Raleigh General Hospital February 1981 - May 1983

1710 Harper Road, Beckley, WV

RN Staff Nurse Medical-Surgical Unit/Labor and Delivery

EDUCATION/CREDENTIALS/CERTIFICATES/VOLUNTEER

EDUCATE-THE-EDUCATOR BLS/CPR/FIRST AIDE

Bachelor of Science in Nursing, Chamberlain College of Nursing 2017

RN-BSN Weekend College, College of Mt. Saint Joseph 1996

Associate Degree in Nursing, West Virginia Tech University 1981

Duke Energy Volunteer for Homeless/Free Store Food Bank, Cincinnati, Ohio

St. Francis de Sales Parish Council, Cincinnati, Ohio

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