Linda M. Moreman, RN, BSN

**** **** ******* ******* *****, Fort Pierce, FL 34951

Cellular: 772-***-**** adx6u6@r.postjobfree.com

Professional Experience

Having worked for Humana for two years and nine plus years with United HealthCare Clinical Services, what I bring to the table is the knowledge and understanding of what insurance companies are looking when reviewing claims, and subsequently denying for poor coding practices and inaccurate clinical documentation. I have over 10 years of experience dealing with ICD-9/10CM, MS-DRG, AP-DRG, and APR-DRG with a broad knowledge of medical claims billing/payment systems provider billing guidelines, payer reimbursement policies, medical necessity criteria, and coding terminology. I have over a year of experience working in medical appeals. I have expert coding knowledge (DRG & ICD-10), and am a BSN Registered Nurse, RN, working toward my coding/clinical documentation certification. I have worked from home for over ten years and have a dedicated office in my home with access to high speed internet and VPN technology. I am currently held to daily production goals and have consistently met my quality audits on a monthly basis (I can provide the documentation that speaks to this from my annual reviews).

United Healthcare Clinical Services – July 29, 2016 – Current

Clinical Appeals Registered Nurse – June 2022

Primary Responsibilities:

Completing denials (Medical necessity vs. Coding vs. Technical) and identifying the root-cause

Conducting reviews and responding to insurance denials. Writes concise, factual letters and provides medical record documentation to support appeal. Effectively communicates verbally with external and internal customers to ensure argument for appeal is clearly presented. Denials process, including subsequent appeal to health insurance

Assures appropriate action is taken within appeal time frames to address denials

Collaborates with other departments/resources/entities as applicable to ensure the most optimal appeal outcome

Utilizes appropriate applications (ATS, Epic, Gosmos, Facets, HSR/ICUE) to accurately track clinical denial data;

Experience in using hospital applications including but not limited to EMR (Cerner, Meditech, etc.), Encoders, and CDM tools

Has extensive knowledge of applicable Medicare, Medicaid, or Commercial determinations and policies, including Local Coverage Determinations (LCD/LCA), National Coverage Determinations (NCD), Policy Bulletins, etc.

Ability to accurately apply utilization review criteria (InterQual and MCG) when necessary

Knowledge of and the ability to: identify the ICD-10-CM/PCS code assignment, code sequencing, discharge disposition, CPT/HCPCS in accordance with CMS requirements, Official Guidelines for Coding and Reporting, and Coding Clinic guidance

Works in conjunction with multiple units including CDI, coding, legal, Mid/Back rev cycle teams, Providers, payers, and other vendors

Inpatient Care Manager – Telecommuter August 2016 – May 2022

Perform utilization and concurrent review of inpatient cases using Milliman criteria

Conduct clinical chart assessments

Build and maintain relationships

Discuss cases with treating physicians and other healthcare professionals to better understand plans-of-care

Participate in rounds with the Medical Director and discussing cases as needed

Determine need, if any, for intervention and discussing with Case Managers and physicians

Identify and evaluate delays in care

Initiate a discharge planning and readmission prevention plan

Approve bed days for inpatient cases (when applicable)

Arrange alternative care services; contact and maintain communication with acute long term care, acute rehabilitation, or skilled nursing facilities to move patients through the care continuum

Gather clinical information to assess and expedite care needs

Facilitate timely and appropriate care and effective discharge planning

Participate in team meetings, education discussions, and related activities

Maintain appropriate documentation

Consult with the Medical Director as needed to troubleshoot difficult or complex cases

Identify opportunities for improved communication or processes

Participate in telephonic and in-person staff meetings

WellMed Medical Management – OPTUM May 2014 – July 2016

Transition Care Manager

I was responsible for utilization management and inpatient care management coordination and perform reviews of current inpatient services, and determine medical appropriateness of inpatient and outpatient services by following medical guidelines and benefit determination.

identify, screen, track, monitor and coordinate the care of members with multiple co-morbidities, psychosocial needs, transition needs and develop a nursing plan of care as well as prospective, concurrent, and retrospective utilization review of inpatient services.

act as an advocate for members and their families by linking them to other members of the care team to help them gain knowledge of their disease process and to identify community resources for continued growth toward the maximum level of independence.

responsible for the case management activities across the continuum of care including coordination of care, medical management consulting and may also provide health education, coaching and treatment decision support for members.

participate in interdisciplinary conferences and Patient Care Coordination Meeting (PCC) to review clinical assessments, update care plans and determine follow-up frequency with the team.

Humana - May 2012 – May 2014

Clinical Nurse Liaison

On-site utilization review nurse supporting acute care hospitals and SNFs in Martin and Saint County. I collaborate with other health care givers in reviewing actual and proposed medical care and services against established CMS Coverage Guidelines review criteria. Manage network participation, care with specialty networks, care with DME providers and transfers to alternative levels of care using your knowledge of benefit plan design .

Recommended services for Humana Plan members utilizing care alternatives available within the community and nationally

Identify potentially unnecessary services and care delivery settings, and recommend alternatives if appropriate by analyzing clinical protocols

Examine clinical programs information to identify members for specific case management and/or disease management activities or interventions by utilizing established screening criteria.

Conduct admission review, post discharge calls, and discharge planning

Participated in a specials project HEDIS measures review for a large group of physicians in Martin County. I am familiar with the importance of HEDIS measures and providing education to the physicians/staff regarding these measures. I am trained in MediConnect and EPMI Humana systems.

Martin Memorial Health Systems – 2000 - 2012

Healthcare Risk Manager

Managed the day-to-day risk situations with the stakeholders and reduced the risk of reoccurrence while also improving quality of care and patient and staff safety. I responded to actual and potential sentinel events and represent Risk Management (RM) at the Root Cause Analysis and Failure Mode & Effects Analysis team meetings held subsequent to reportable events. I established and developed departmental policies and procedures, objectives, performance improvement plans and safety standards. I created the analysis of events with or without injury that may meet the criteria for reporting to the FDA, JCAHO and/or the Agency for Healthcare Administration (including Code 15 and Annual AHCA reports).

Clinical Claims Specialist – Corporate Risk Management (Legal Division).

Developed an efficient and effective management plan for all professional liability, general liability, workers compensation and medical malpractice claims for a Self-Insured Program. I handled all claims from inception to trial for two hospitals, three MediCenters, two Diagnostic Centers, three Wellness Centers, and multiple physician practices. I established initial reserves with management, worked with in-house and outside counsel, facilitated early resolution and minimized risk of financial loss. I reported to internal and external auditor as well as an actuary for all in-house claim reserves. Conducted interviews with witnesses and attended depositions with outside counsel.

Education and Training

ASHRM – Completed Healthcare Risk Manager Program

Baccalaureate of Science in Nursing

Barry University, Miami Shores, Florida, GPA: 3.73

Associate Degree in Nursing

Palm Beach Community College, Lake Worth, Florida, GPA:3.54

Licensure and Certification

04/2020 Florida License -- RN 2737262 - Florida is part of the Nurse Licensure Compact (NLC).

09/2022 MCG Certification

05/2020 Certified Case Manager

06/2002 Certified Health Care Risk Manager

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