Customer Service Nursing Care

Lisa Milton, LVN

Clinical Investigator, Staff Med/ Surg Trauma Resistor Abstractor, HEDIS Abstractor, Coding North Richland Hills, TX 76180 *********@*****.*** +1-817-***-****

•An experienced Licensed Vocational Nurse, LVN License # 302279, by Texas Board of Nursing

•Expertise in abstracting the information obtained from medical records copied from physician offices/healthcare facilities and data entered into the HEDIS Software.

•Skilled in keeping confidential all medical records that are copied or received, in accordance with federal and local requirements. HEDIS Reviewer must be able to attain an inter-rater reliability score of 95% or higher to remain eligible for continued employment for the duration of the project.

•Efficient in obtaining quality detail report and flags patient's charts with missing measures, analyze data, evaluate for possible data integrity and data deficits and document findings

•Proficient in Coding and abstracting CPT, ICD9, ICD10, excel spreadsheets, self-scheduled, working knowledge of Specifications and Guidelines regarding HEDIS, Stars, InterQual, CMS medical necessity criteria.

•Interested in WAH, Local to Fort Worth, TX and is available for Phone/ Virtual Interview immediately Authorized to work in the US for any employer

Work Experience

LVN Med Surg Trauma Telemetry

Medical City Hospital North Hills - Texas

December 2022 to Present

Assist in the determination of predictable healthcare needs of clients within structured healthcare settings who are experiencing common, well-defined health problems with predictable outcomes.

Utilize a systematic approach to provide individualized, goal directed, and age specific care.

Collect data and perform focused nursing assessments.

Participate in the planning of nursing care needs for patients, and in modifying the nursing care plan for assigned patients.

Implement appropriate aspects of care within the LVN scope of practice, including compliance with other laws applicable to the practice setting.

Implement the teaching plan for patients with common health problems and well-defined learning needs.

Provide direct basic care to assigned multiple patients in a structured setting.

Assist in the evaluation of the patient’s responses and outcomes to therapeutic interventions.

Utilize a problem-solving approach as the basis for decision making in practice

Trauma Registrar Abstractor

HCA Parallon - Texas

October 2021 to December 2022

Abstracts physiological and anatomical data on trauma patients for inclusion into a trauma data collection system

•Performs identification, prioritization and injury coding of trauma patients for inclusion into a trauma data collection system

•Performs duties to support the abstraction of quality trauma data for use locally, statewide and nationally

•Performs other trauma registry duties as may be required per the contract

•Maintains confidentiality and security of patient data at all times

•Abstracts data from the medical record according to the requirements of the hospital, state and national trauma registry data definitions including demographic characteristics, prehospital information, initial hospital treatment, operating room usage, outcome and final disposition.

•Participates in periodic quality reviews

•Interacts in a positive manner with client(s)

•Remotely accesses electronic health records and trauma data collection systems

•have the ability to code in ICD-10-CM specific to injuries and mechanism of injuries

•have the ability to code in ICD-10-PCS

•have the ability to assign severity of injury utilizing the AAAM Abbreviated Injury Scale

•able to analyze and process detail-oriented information

•able to read and understand data definitions using a standard data dictionary

•self-motivated and able to work independently

•very comfortable working with technology and personal computer

Clinical Investigator, Waste, Abuse and Fraud, E&I and MMR

OPTUM

November 2018 to April 2019 seasonal)

•Performs clinical coverage review of CPT and HCPCS coded claims in a telecommuting work environment determining payment recommendation

•Determines appropriate level of service utilizing Evaluation and Management Coding principles

•Ensures adherence to state and federal compliance policies, reimbursement policies and contract compliance

•Responsible for Clinical and Coding expertise in the application of medical and reimbursement policies within the claim adjudication process through file review.

o This could include Medical Director/physician consultations, interpretation of state and federal mandates, applicable benefit language, medical and reimbursement policies and consideration of relevant clinical information

•Performs clinical coverage review of post-service, pre-payment claims, which requires interpretation of state and federal mandates, applicable benefit language, medical & reimbursement policies, coding requirements and consideration of relevant clinical information on claims with aberrant billing patterns • Performs clinical coding review to ensure accuracy of medical coding and utilizes clinical expertise and judgment to determine correct coding & billing

Identifies aberrant billing patterns and trends, evidence of fraud, waste or abuse, and recommends providers to be flagged for review

•Maintains and manages daily case review assignments, with accountability to quality and productivity standards

•Medicare Advantage, Original Medicare and or Medicaid appeal regulations.

•Provides clinical support and expertise to the other investigative and analytical areas.

•Participates in team and network meetings, engaging in a collaborative work environment.

•Medicare claim process and plan rules along with working with of ICD 9, ICD10

•Serves as a clinical resource to other areas within the clinical investigative team

LVN II

Baylor Scott and White, HTPN Liver Consultants of Texas

June 2018 to October 2018

•Implements the nursing plan of care and measures to promote a safe environment for patients. Accepts only those nursing assignments that take into consideration client safety and that are commensurate with the nurse's educational preparation, experience, knowledge, and physical and emotional ability.

•Administers medications and IV therapy in accordance with the regulatory requirements, Texas Board of Nursing and Baylor Scott and White Health policies and procedures.

•Transition Care Management Provides telephonic post-discharge support to assist the defined population of patients in meeting short and long-term goals with regards to their overall well-being. The TCC may collaborate with other care team members such as home health providers to avoid redundant telephonic follow up and coordinate care.

•Coordinates comprehensive post discharge health care services, support programs, and referrals for community-based services

•Repots and documents patient status, nursing care rendered, physician, and dentist or podiatrist orders, and administration of medication and treatments and patient responses.

•Observes patients, symptoms, signs and progress and report to Physicians. Uses observational data inworking cooperatively with other health team members in modifying plans of care.

•Obtains instruction and supervision as necessary when implementing nursing procedures or practices. Utilizes a systematic approach to provide individualized, goal-directed nursing care.

•Attends educational meetings and conferences in order to maintain and enhance Nursing skill. Clinical competence and leadership skill for professional growth and development.

•Makes a reasonable effort to obtain orientation/training for competency when encountering new equipment and technology or unfamiliar care situations.

•Receives and transcribes Physicians' Orders received by telephone. Interacts with patients and families in a professional manner; and explains treatments, procedures, and Nursing care plan. Maintains clean and efficient patient environment such as properly removing soiled linen, disposing of waste, and maintain

•Equipment as required.

Licensed Vocational Nurse

Mesa Springs Hospital - Fort Worth, TX

July 2017 to February 2018

•Support the organization, program and unit philosophy of care

•Works with chemical dependency, dual diagnosis, psychiatric and geriatric patients. • Coordinate and deliver quality general and psychiatric nursing care to patients,

•Ensure medical Orders are followed, initiate and follow treatment planning.

•Patient assessments, family motivations, treatment planning and communication with external review organizations or comparable entities. • Act as a patient advocate at all times.

HEDIS NURSE REVIEWER, Quality

Cigna - Irving, TX

September 2015 to February 2017

•The HEDIS Reviewer works under the direction of the HEDIS Clinical Lead and other CIGNA personnel.

•This is a remote based position and the HEDIS reviewer is responsible for working independently to review and abstract pertinent medical record information in accordance with the HEDIS Technical Specifications.

•The HEDIS reviewer is responsible for setting-up and maintaining their own schedule, to include contacting their assigned offices to conduct the HEDIS review.

•The information to be abstracted will be obtained from medical records copied from physician offices/healthcare facilities and data entered into the HEDIS Software.

•All medical records that are copied or received must be kept confidential, in accordance with federal and local requirements. HEDIS Reviewer must be able to attain an inter-rater reliability score of 95% or higher to remain eligible for continued employment for the duration of the project.

•Additionally, the HEDIS Reviewer may collaborate with non-clinical personnel regarding collection of medical records from physician offices for additional medical record pursuits or may collect the information themselves and other duties as assigned.

•This assignment would require travel to and from provider offices on a daily basis and could possibly require overnight travel on occasion, with advance notice.

•Coding and abstracting CPT, ICD9, ICD10. DRG, HCPCS

•Responsible for the supervision of Care Managers in Oklahoma, Texas, Kansas, Arkansas and Missouri. Maintains education/knowledge base of HEDIS/STARs standards and guidelines

•This is a remote based position and the HEDIS reviewer is responsible for working independently to review and abstract pertinent medical record information in accordance with the HEDIS Technical Specifications.

•Skills Used: Personal computers, self-scheduled, excel spreadsheets

HEDIS Abstractor, Field Reviewer

Change Health Care/Altegra, Remote Office Base

October 2016 to October 2016

•Identify appropriate information from medical records according to NCQA HEDIS Technical Specifications and Change Healthcare guidelines.

•Enter data into Change Healthcare proprietary software.

•Maintain accuracy thresholds as set forth by Change Healthcare.

•Check chart assignments every day and accurately report all hours worked on a weekly basis.

•Report work-related concerns to assigned Clinical Advocate and, if not adequately addressed, to Sr. Manager of Clinical Operations.

•Comply with HIPAA laws and regulations.

Participate in testing and training as required by the Company

Quality Coordinator, HEDIS

United Health Group, Well Med - Fort Worth, TX

February 2015 to October 2015

•Analyze data, evaluate for possible data integrity and data deficits and document findings

•Analyze and trend HEDIS/STAR rates, identify barriers to improvement of rates and create interpretive exhibits

•Obtains quality detail report and flags patient's charts with missing measures

•Used ePRG to provide reports

•Works closely with local leadership to execute quality strategies

•Supports and assists PCPs/clinics with quality data collection

•Provides reports and monitors performance at local level

•Engages PCP and clinic staff in developing strategies to close quality gaps

•Ensures accurate and adequate payment based on expected medical costs.

•Supports and improves communications between market and corporate departments

•Maintains education/knowledge base of HEDIS/STARs standards and guidelines

Assistant Director of Nursing, Staff Developer, Infection Control Prevention, DS

Mira Vista Court - Fort Worth, TX

February 2014 to February 2015

•Assist Director of Nursing with overall management of the Nursing department

•Assist in maintaining quality nursing care for all residents

•Participates and assists in departmental studies and projects as assigned.

•Performs chart audits, MAR and Treatment reviews.

•Assists in assessing learning needs of personnel in order to meet the needs of the consumer, organization, and employee

•Participates in the quality assessment and improvement process and activities.

•May serve as facility QI Coordinator.

•Member of QI Committee.

•Abstracts statistical data for discharge records in accordance with the Uniform

•Hospital Discharge Data Sets (UHDDS) standards, using the hospital's computer

•Abstracting system. Follows Facility and Department policies and procedures. • Participates in coding education programs. Maintains current and accurate

•Knowledge of coding procedures and guidelines.

•Maintains current MDS status of each patient/resident in accordance with state and federal guidelines as required under the Omnibus Budget Reconciliation Act (OBRA), Medicare PPS and any Medicaid payment system as applicable.

•Maintain all staffing and development processes

•Serve as Director of Nursing is absence of the Director

•Supervised and assessed vital changes in residents’ condition by monitoring vital signs, symptoms and test results Participates in the quality assessment and improvement process and activities.

•Served as facility QI Coordinator.

•Member of QI Committee.

•Abstracts statistical data for discharge records in accordance with the Uniform

•Hospital Discharge Data Sets (UHDDS) standards, using the hospital's computer

•Abstracting system. Follows Facility and Department policies and procedures.

•Participates in coding education programs. Maintains current and accurate

•Continually documenting Member response to plan and interventions. Acting as Member/staff/community liaison.

•Development of members transition process to home and or long term care.

•Knowledge of coding procedures and guidelines.

•Ensures accurate and adequate payment based on expected medical costs

•Maintains current MDS status of each patient/resident in accordance with state and federal guidelines as required under the Omnibus Budget Reconciliation Act (OBRA), Medicare PPS and any Medicaid payment system as applicable.

•Serve as Director of Nursing is absence of the Director

LVN/Nursing Assessment Coordinator

City view Care Center - Fort Worth, TX

November 2011 to April 2014

•Provide skilled professional nursing care to patients on inpatient units: express recovery and long term care

•MDS nurse

•New admit and intake nurse

•Document and record patients’ health status and nursing care

•Participate in multidisciplinary care rounds

•Healthcare experience to include experience in a managed care setting

•Experience with data analysis/quality chart reviews

•Must be able to review data and provide recommendations for improvement

•Experienced using Microsoft office applications, including databases, word-processing, and excel spreadsheets

•Supervise the care provided by nursing aides

LVN Clinic Nurse, Med-Surgery Floor/Unit

Cityview Care Center - Fort Worth, TX

April 2012 to December 2012

•Delivery of healthcare to infants, children, adolescents and geriatrics

•Assist with routine and acute clinic visits• Assist with minor office procedures and test

•Schedule routine and annual appointments.

•Coordination of HEDIS and STARs data gathering process within the clinic setting

•Supports and improves communications between market and corporate departments.

•Maintains education/knowledge base of HEDIS/STARs standards and guidelines.

•Performs all other related duties as assigned

•Assist coordinator or manager with administrative duties as assigned

•Healthcare experience to include experience in a managed care setting

•LVN assists physicians with examinations, treatments and special procedures and performs services requiring technical and manual skills as directed by the Registered Nurse.

•LVN administers medication, performs treatments and patient care responsibilities as prescribed• LVN assists with admitting, discharging and transferring of patients

LVN Staff Nurse

Home Health, No Place Like Home Hospice - Fort Worth, TX

September 2011 to April 2012

•Administer pain medication for pain and comfort

•Monitor vital signs and fluid intake and output

•Provide dressing changes to wounds

•Provide ADL's and grooming

•Provide companionship to client and family

Customer Service Representative Medicaid and Medicare

CGI - Fort Worth, TX

November 2008 to September 2011

CGI

•Provide excellent communication and customer service

•Managed care. Payments.

•Complete property, casualty and auto claims

•Underwriter for new insurance policies

•Call center operator for company collections

Computer Lab Assistant

Crowley ISD - Fort Worth, TX

August 2008 to November 2008

•Assist students and teachers with use of computers

•Maintain operation of computers, printers and instructional software

•Assist with student modality training

•Assist with training new staff members

Education

License

Texas State Board of Nursing December 2020

Medical Coding Academy Dallas - Dallas, TX

January 2016

Vocational

Concorde Career Institute

April 2009 to August 2010

Certification

Tarrant Community College

July 1999 to February 2000

High school diploma in Early Childhood Development

Lamar University

August 1982 to May 1984

Skills

•CPT Coding (3 years)

•ICD-10 (2 years)

•Insurance Verification (10+ years)

•HEDIS (10+ years)

•Managed Care

•NCQA Standards (8 years)

•MDS (2 years)

•ICD-9

•Medical terminology (10+ years)

•Typing

•Windows

•Medical Coding

•Infection Control Training

•Nursing (10+ years)

•Medical Records (10+ years)

•Quality Assurance

•Medical Billing

•Employee Orientation

•EMR Systems

Certifications and Licenses

Medical Billing Certification

LVN

September 2011 to Present

LPN

AED Certification

CPR Certification

Epic Certification

Assessments

Medical Billing — Proficient

April 2020

Understanding the procedures and forms used for medical billing.

Full results: Proficient

Indeed Assessments provides skills tests that are not indicative of a license or certification, or continued development in any professional field.

Additional Information

Skills:

•Personal computers, self scheduled, excel spreadsheets

•Leadership: Function as the Assistant Director of Nursing, Staff Developer and NAC on a daily basisand in the absence of the Director of Nursing, to ensure a consistent flow of patient care and health outcomes. Ability to handle multiple projects and prioritize.

•Management: Assist with day-to-day operations, such as labor management, control of expenses,monitor and assist staff with daily patient care and collecting quality data; Implementation of education training, standards of practice and accountability for policies and procedures. I have extensive computer skills - MS Office (Windows, Excel and Outlook).

•State Regulations: Consistent training and observation for adherence to State medical care rules andregulations to remain a deficiency-free facility.

•LVN Charge Nurse: Working with Adults with Developmental Disabilities. Completed patientassessment, medication administration, wound care, treatments, physician rounds, performed skilled nursing duties under the direction of the facility physician and RN.

•Geriatric Facility LVN Charge Nurse: Completed patient assessment, medication administration,wound care, treatments, physician rounds, and performed skilled nursing duties under the direction of the facility physician and RN

•Field LVN: Complete patient assessment, patient/family education, medication administration,documentation, data entry and continuous care of the dying patient. Performed skilled nursing procedures under the direction of the Hospice Physician. Patient/Family/Community Liaison

•CQI Nurse: Performing routine and continual quality assurance and chart auditing functions. Paringwith Administration to review and modify policy and procedure when necessary to meet State, Federal and Program requirements. Participate in updating agency "Resource Data Base." Assist with inservice and educational events within the agency. Working knowledge of Specifications and Guidelines regarding HEDIS, Stars, InterQual,CMS medical necessity criteria.

•Customer Service Specialist

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