Compliance Auditor Utilization Review

Yarnell H. McGee

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

Katy, Texas ****3

713-***-****

PROFILE

I have developed a utilization review work format designed to improve my time management during heavy caseloads. I have also been working on databases developed by myself to trend denial information. I hope to use this information to pinpoint any factors that are reoccurring in denial categories. I have established a communication system among all multidisciplinary team members to keep them abreast of insurance patients. I have learned thru my utilization experience how to prior authorize day surgery and precept inpatient admissions. I also have taken the initiative to precept patients who have not been identified as insurance clients when informed by physicians, social workers, nurses and discharge planners. I have the ability to work independently and ask for assistance as needed. I am a team player as well as a team member. I have also had the role and responsibility for gathering data and compiling it for monthly utilization review reports. I have oriented new utilization review nurses and served as a resource person. I hold Certifications as a Professional Case Manager, and Professional Coder. I participated in a Kaizen Training Session. EXPERIENCE

Medical Compliance Auditor; Houston, Texas —2021

I perform audits (random) in compliance with TAC (Texas Administrative Code) 353.502 and 370.502. These audits are standard detection algorithms used by the Special Investigative Units for Texas Children’s

Health Plan to detect potential Fraud, Waste and Abuse. My role is to review and detect violations of the NCCI (National Correct Coding Initiative) edits, Texas Medicaid Provider Procedures Manual Guidelines, Center for Medicare and Medicaid Services (CMS), Texas Administrative Codes (TAC) and Managed Care Organizations Procedures and Guidelines. I review claims randomly selected from a pool of claims that have historically included problematic CPT (Current Procedural Terminology) codes, provider types or other issues. Medical Records are requested from the provider, and I review for appropriate coding and documentation. The identification of a significant issue may result in opening an investigation to request additional medical records. Participated in SIU Recoveries thru medical review of audit records. Identified Gross is $4,679,282 year to date with $555,553 net recoveries identified for August 2022. Participated 80%-90% of 2022 SIU Work Plan activities with Research and data mining/analysis ongoing. Denials and Appeal Coordinator; Houston, Texas — 2016- 2021 I analyze requests against regulatory and decision making guidelines and benefit allowances. I collaborate with the Texas Children’s Health Plan (TCHP) medical director/physician reviewer, network physicians and network facilities to ensure consistent clinical evaluations and processing of cases not meeting Texas Children’s Health Plan (TCHP) medical necessity criteria or those appealed for reasons of medical necessity decisions. I perform all necessary communication and documentation functions. Utilization Resource Manager, Utilization Management; Houston, Texas—2004- 2016 Utilization Review transitioned from Quality Management and merged with Social Work Service and Discharge Planning to form Case Management. Responsible for assigned Inpatient Clinical Nurse Case Managers as well as Emergency Center Clinical Nurse Case Managers at Lyndon Baines Johnson, a hospital within the Harris County Hospital District System. Developed processes and systems for Clinical Nurse Case Managers, since Case Management was new to Harris County Hospital District. Assumed responsibility for Bed Management at Lyndon Baines Johnson General Hospital. Responsible for three areas where two of the three were 24/7 operations. Role transitioned from Inpatient setting to Outpatient setting, where responsibility shifted to Outside Medical Services. Focus was outsourcing PET/CT Scans and other procedures that could not be performed within the Harris Health System (name transitioned from Harris County Hospital District) due to capability. Ensued requests were properly coded with diagnosis and procedure codes. All requests meet financial clearance, which may have involved obtaining authorizations from third party payers. Medical necessity for all non-third party payor requests was handled with either application of a screening criteria or secondary medical review thru a medical physician reviewer. Once requests were processed, appointments were scheduled with patients for procedures and follow up of results. Instituted Daily Huddles to keep staff engaged on daily operations of department. Huddles helped to foster effective communication by providing opportunities for teaching, coaching and real time organizational updates in addition to staff meetings. Moreover, Huddles helped to boost employee morale by providing a positive work environment to serve as a platform for leadership development. Huddles also helped to foster team building and ultimately improved employee satisfaction and retention. Lastly, data trends were also analyzed to determine opportunities for improving work flow in the department. Quality Management Utilization Coordinator; Houston, Texas — 1998-2004 I learned the utilization review process by first hand experience at Lyndon Baines Johnson, a hospital within the Harris County Hospital System. I was assigned Medicine, Surgery, Family Practice, Women and Children as well as Nursery Services. I covered Observation, Day Surgery, Medicine and patients greater than five days for appropriate length of stay criteria. I was also responsible for reviewing payer source charts for appropriate Admission status and referring cases to the physician reviewer as needed. I sent charts/records to appropriate faculty staff for appeal decisions. At times, I covered the house (all bedded clients at Lyndon Baines Johnson General Hospital) for insurance patients when the only other utilization coordinator was absent. This was my assignment and work schedule for at least one and a half years until other nurses were hired for these areas. After the other utilization coordinators were hired, my assigned areas covered were Medicine, Surgery and Family Practice Services. My responsibilities included calling in daily clinical information to insurance companies to obtain approval for the insurance patients’ hospital stays. I also obtained precerts for insurance clients for their hospital admissions that had not been previously identified after notification by multidisciplinary staff that clients had insurance coverage. I also compiled data from the other coordinators to forward for monthly reports. I was responsible for following length of stay patients in my areas. I was also responsible for following a hundred percent review of Medicaid and pending Medicaid patients for acute inpatient status. I have developed and continued to strive in improving my communication network with physicians, social workers and discharge planners to provide continuity of care for my patient population. I educated the physicians on appropriate acute inpatient criteria and facilitated peer to peer consults between our physicians and the medical directors of insurance companies as needed. Staff Registered Nurse; Houston, Texas — 1996- 1998 I transferred from Ben Taub General Hospital to the sister hospital, Lyndon Baines Johnson General Hospital within the Harris County Hospital District System to learn its dynamics in the pediatric setting. Staff Registered Nurse; Houston, Texas — 1995- 1996 I transferred to the Obstetrics Post Anesthesia Unit in Labor and Delivery at Ben Taub General Hospital within the Harris County Hospital District System to broaden my knowledge base. Assistant Head Nurse; Houston, Texas — 1991- 1995

I was promoted to this middle management position at Ben Taub General Hospital within the Harris County Hospital District System. I was responsible for the Level II nurseries on the night shift, which included High Risk and Low Risk nurseries. I problem solved and handled situations for both units. I was responsible for making assignments, counseling per handbook of staff and evaluating staff on my shift. Staff Registered Nurse; Houston, Texas — 1990- 1991 I transferred to High Risk Nursery at Ben Taub General Hospital within the Harris County Hospital District System to broaden my knowledge base.

Staff Registered Nurse; Houston, Texas — 1989- 1990 I was a part of the pediatric staff chosen to open a separate Pediatric Intermediate Unit in the new Ben Taub General Hospital within the Harris County Hospital District System. Staff Registered Nurse; Houston, Texas — 1987- 1989 My first job started in pediatrics at Ben Taub General Hospital within the Harris County Hospital District System. I assumed role of charge nurse when assigned. EDUCATION

Prairie View A & M University — Baccalaureate Degree in Nursing, 1986 SKILLS

My skills include, but not limited to the following areas: effective communication, Microsoft office

(Outlook, Word and Excel); work independently, handle confidential patient information, problem solve, multi-task, pediatric experience, certified professional coder and medical compliance auditor

(certification pending).