R.N Case Manager

Penny Powell

RN

*********@*****.***

Cell #318-***-****

Summary:

● Dedicated registered nurse (RN) with varying experience in Medical Record Auditing for medical necessity, DRG validation and coding compliance.

● RAC/chart audits, using QA/QI measures for CMS/Medicare and private insurance companies.

● Able to performed inpatient medical pre-bill reviews for identifying optimal DRG assignments to prevent potential re-bill.

● Previously performed audits for the BPCI program and assigning ICD 9 and 10 codes to obtain MS- DRGS by reviewing medical charts.

● Previously contracted with Louisiana Medicaid with chart audits, clinic inspections, and provided teaching of Medicaid rules and regulations.

● Worked in Medical/Surgical department, NICU, Prison nursing and with case management/discharge planning and education/teaching experience

● Worked for the Department of Defense as a Clinical Nurse during Desert Storm.

● A proven ability to build positive relationships with clients, family members, physicians and other medical professionals.

SCOPE OF CODING APPLICATIONS AND ACTIVITIES –

RN/HII NURSE PROGRAM: Inpatient retrospective reviews of “pre-bill” reviews for multiple facilities via remotely using E.H.R’s. Identified potential opportunities in documentation and identify the optimal DRG assignment which allows the medical chart to reflect the most accurate DRG and codes. This will prevent the claim from being identified as a potential re-bill. Able to Identify the need for M.D's queries and construct these queries using the AHIMA query guidelines and clinical indicators.

BPCI PROGRAM: Inpatient/Observation admission coding verification with utilizing ICD 9 and ICD 10 guidelines the diagnoses or procedures in all departments in 8 hospitals across the U.S. Also audited the reason of admission and confirmation of proper coding sequences. Verified proper final billing and DRG validation. The departments consisted of Medical-surgical, Surgery, Cardiology, Thoracic, GI, OB/GYN, Renal, Respiratory, Endocrinology, Psychology and Radiology, and any and all surgeries/procedures involved in these departments. RAC: Audited inpatient/observation admissions for medical necessity and clinical and DRG validation with code sequencing utilizing ICD 9 guidelines for the Region A hospitals in all departments of the hospitals. Identified and corrected Medicare improper payments through the efficient detection and collection of overpayments made on claims of health care services provided to Medicare beneficiaries, and the identification of underpayments to providers so that the CMS can implement actions that will prevent future improper payments in Region A. Also performed Managed Care audits utilization CPT guidelines with Physical/Occupational therapists and DME documentation audits for any coding errors. Also audited proper completion of UBO4 documentation.

Experience:

R.N./Hii Nurse, ARDENT HEALTH, NASHVILLE TN-7/2016 TO 12/2022

● Performing inpatient medical reviews “pre-bill” reviews for multiple major facilities that belong to Ardent.

● Identify potential opportunities in documentation and identify the optimal DRG assignment which allows the record to reflect the most accurate DRG to prevent the claim from being identified as a potential re-bill.

● Communicate via email to the coding professionals (CDI’s and coders) the potential findings for potential re-bills.

● Identified the need for clinical validation queries and able to construct the queries using the AHIMA query guidelines.

● Followed up with queries to ensure the physicians answered and document via monthly spreadsheet how the query reflected in the final DRG.

● A strong knowledge with ICD-9 and 10-CM/PCS guidelines, concepts and coding clinics.

● Constructed a monthly productivity spreadsheet to submit to the supervisor.

● Work remotely from my home office.

R.N. CODER, EVICORE; FRANKLIN TN- 10/2014 TO 6/2016

● Performing BPCI audits for a CMS/Medicare contract.

● Audit medical charts and I assign ICD 9 and 10 codes for admission diagnoses and I assign MS-DRG’s.

● A strong knowledge of Inpatient and Outpatient documentation requirements as well as assigning inpatient ICD-9 and 10 coding.

● Assigned priority levels to assure the case managers see the clients according to the need of care. I have performed as a team leader for my department when my supervisor was unavailable.

● Assisted the team leader with completing daily spreadsheets required by the upper management and quality assurance audits of my co-worker’s documentation to assure compliance of policies and procedures assigned to the department.

● Work remotely from my home office.

RN Nurse Auditor: PERFORMANT CORPORATION, SAN ANGELO, TEXAS/LIVERMORE, CA - 03/2012 TO 10/2014

● Performed RAC audits for CMS/Medicare and audits for private insurance companies.

● Audit medical charts for medical necessity using McKesson InterQual criteria, DRG and clinical validation, coding and therapy cap compliance.

● Performed quality assurance audits with the coders and other fellow employees’ documentation. A strong knowledge of Inpatient and Outpatient documentation requirements as well as inpatient ICD-9 coding and HCPCS. Also worked for the research team, writing Medicare/CMS LCD rules/edits policies for the company wide education.

RN Field Nurse, AUTOMATED HEALTH SYSTEMS, BATON ROUGE, LA - 08/2010 TO 03/2012

● Worked as Region 6 and 7 Compliance Field Nurse for KidMed and CommunityCare, which are programs for Louisiana Medicaid. Audited charts and documentation using Medicaid and HEDIS guidelines.

● Examined equipment to assess if Medicaid providers are following Department Health and Hospitals' protocols and policies.

● Followed up on complaints from Medicaid recipients and/or providers/Doctors and Nurse Practitioner to assure quality care.

● Traveled to 16 parishes in the State of Louisiana to assure good quality care for clients with Medicaid.

● Worked from my home office outside of Shreveport, LA and traveled to Baton Rouge and New Orleans on a regular basis for training, meetings, and conferences.

● The KidMed and CommunityCare programs were changed over to HMO’s and my contract ended in 2012.

RN/Case Manager, STAT HOME HEALTH, SHREVEPORT, LA - 12/08 TO 09/2010

● Served served as RN/Case Manager at a home health agency with an average of 350 to 575 clients.

● Assigned to the Advanced Illness Management program and played a key role in interdisciplinary team of doctors, RNs, social workers, and the members of St. Joseph’s hospice.

● A strong knowledge of OASIS documentation with home health as well as inpatient ICD-9 coding and HCPCS coding.

● Actively participated in worked development and implementation of client treatment plans for transitioning to hospice or providing care in the home health setting.

● Also ensured that doctor’s orders were effectively carried out by the field personnel including RNs, CNAs, Physical Therapists, and Occupational Therapists. Night L.P.N. Instructor, LOUISIANA STATE UNIVERSITY, SHREVEPORT, LA - 2008 TO 12/2010

● Seved as a Night L.P.N. Instructor for a continue education department with L.S.U. with an average of 20 students.

● Provided classroom and clinical instruction to the students. At the time of this employment, I was alternating between full time and part time hours as I was caring for my terminally ill Mother. At the time of her death, I needed to obtain regular full time hours.

RN/Case Manager, LOUISIANA STATE HEALTH AND SCIENCE CENTER, SHREVEPORT, LA - 2006 TO 2008

● Served as RN/Case Manager for the Oncology/Bone Marrow Transplant Floor and Clinic.

● Provided education, discharge planning, and medication assistance for the patients that were admitted.

● Performed medical necessity audits using McKesson InterQual criteria for outpatient versus inpatient admissions. I also actively participated in development and implementation of patient treatment plans for patient’s discharge from the hospital.

● Reviewed the documentation to assess for need of the following placements after discharged from the acute care facility: Skilled Nursing Facility, nursing home, outpatient versus inpatient physical/occupational services, Home Health and Hospice.

● Played a role on an interdisciplinary team of doctors, RNs, and social workers. I had to resign from my position to care for terminally ill Mother. RN/Case Manager and Field nurse, AMERICAN HOME HEALTH AGENCY, SHREVEPORT, LA - 2000 TO 2006

● Served as RN/Case Manager and Field nurse. From the years stated I as a full time and part time RN/Case Manager.

● Actively participated in providing care to patients in their homes by following doctor’s orders.

● Worked with an interdisciplinary team of therapists, CNA’s, and social workers to assure that the patients are properly cared for.

Clinical nurse in the Neonatal Intensive Care, LOUISIANA STATE HEALTH AND SCIENCE UNIVERSITY, SHREVEPORT, LA - 2000 TO 2002

● Worked part-time at American Home Health,

● Worked as a clinical nurse in the Neonatal Intensive Care, Level 3 at LSHSC.

● Provided bedside care, treatment and clinical documentation for infants in the unit. I handled medication administration, dressing changes, IVs and all other aspects of nursing care.

● Present at potentially critical deliveries to stabilize and transport the neonate to the unit.

● Facilitated admissions, discharges and transfers; prepared chart notes and other documentation; and participated on interdisciplinary team. Clinical RN/LPN, DAVID WADE CORRECTIONAL FACILITY/FORCHT WADE CORRECTIONAL FACILITY, HOMER AND KEITHVILLE, LA - 1994-2000

● Served as RN/LPN at an infirmary located within maximum-security correctional facility housing approximately 1,100 inmates.

● Assigned to the Medical Surgical/Mental Health units and I played a key role on an interdisciplinary team of medical doctors, psychiatrists, RNs/LPNs, and correctional officers.

● Actively participated in the development and implementation of individual treatment plans for patients with a broad range of health issues.

● Ensured that doctors' orders were effectively carried out, including testing, medical procedures, consultations and stat orders.

● Acted as the First Responder to any Emergencies that occurred on the prison grounds. L.P.N. US ARMY DEPARTMENT OF DEFENSE, HEILBRONN, GERMANY AND WEST POINT, NY - 1988-1994

● LPN at an Army Family Practice Clinic in Germany.

● Worked in the Immunization, Well Baby and Well Women Clinic.

● Assisted with the military physicals and preparing soldiers for Desert Storm.

● Worked in the Army hospital on the Orthopedic Surgical floor at West Point, NY as a floor/clinical nurse.

Software:

Microsoft Word, Power Point, Excel Spreadsheets, SharePoint, Citrix, TruCode, Outlook, 3M EHR software, Cerner, EHR software, Paragon EHR software, EPIC EHR software, Allscripts, Optum CAC, and Midas.

Skills:

Case Management, NICU Nursing, JCAHO/NCQA Compliance, Medication Administrations, Parent/Patient/Family Education, Patient Advocacy, Patient Assessment, Med/Surg Nursing, Quality & Continuity of Care, QA/QI, Medicaid/Medicare/Managed Care Knowledge, Community Health, Preventive Medicine, ICD 9 and 10 guidelines, Utilization review, InterQual, Milliman, HEDIS, LCD’s, HCC/MCC/CC codes, DRG’s, CMS guidelines and website, Clinical Validation, Disease Management, BPCI Guidelines, Managed Care guidelines, and RAC Guidelines. Education:

1998 Northwestern State University, Shreveport, LA, Associate Degree in Nursing 1987 Red River Technical College, Hope AR, License Practical Nursing Diploma Certifications and Licenses:

Issued 5/18/1998 Louisiana State Board of Nursing, Licensed #RN094630 9/30/2015 completed the ICD - 10 for CDI Boot Camp Online with 14 CEU’s per AAPC. 4/2023 Enrolled in ACDIS CDI Apprenticeship course. When completed, I will enroll in the CCDS certification preparation online course.

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