Jill Cowan, RN, CPUR, CMCN, LNC

**** *. *** ****** ***. 103

Reno, NV 899503

adyiju@r.postjobfree.com

775-***-****

Utilization Review, Quality Assurance, Appeals. Case Management

Occupational Health/Workers’ Compensation, Hospital Bill Auditing

Clinic Management/Clinic Registered Nurse, Discharge Planning, Legal Nurse Consultant/Records Review for Medical Necessity/Merit

Expertise

Perform detailed medical and billing records review, audits, and research. Two-year contract auditing hospital bills for lost revenue. Audited over 900 bills for self-insured client for level of care and medical necessity.

Audited prospective, retrospective, and concurrent utilization review decisions for workers’ compensation and group health

Records review for standard of care and medical necessity for inpatient stays and outpatient authorizations

Evaluated adherence to policies, statues, practice guidelines, and contractual agreements

Expert resource for evidence-based medicine, ACOEM, ODG, CMS, Professional Society Guidelines and Position Statements, California Medical Treatment Utilization Schedule

Proficient with McKesson/InterQual, Milliman Care Guidelines, Hayes, CMS Local/National Coverage Determinations

Ensured high quality appropriate cost-effective care via assessing medical necessity of in-patient and out-patient care in accordance with evidence-based medicine guidelines and the Evidence of Coverage/Plan Document.

Responsible for training nurses and physicians on evidence-based medicine guidelines

Performance of Quality Improvement Projects for URAC Accreditation

Prepare expert witness response and response to appeals

Extensive diverse nursing and medical clinical experience/knowledge

Extensive occupational health experience, Home Health Agency Supervisor, Hospital House Supervisor and Assistant Director of Nursing

Work Experience

Renown Health, Reno, NV – 11/16/2020 – 2/18/2023

Medical Group Consulting RN

I was initially employed as a Registered Nurse at the Vista Primary Care Clinic, responsible for assisting the staff and providers to help the patients achieve and maintain a high level of health. Duties included triaging and responding to patient portal messages for all patients complaining of symptoms, providing direct, telephonic, and written patient education, as well as staff education. After eighteen months the position was eliminated in the Primary Care clinics.

I transferred into the Community Care Management Department, continuing to respond to patient portal messages, as well as follow-up on discharged patients to ensure that the transition of care to home or another level of care was successfully accomplished.

Calabria Group, contract position based at Grand Rounds, Reno, NV 4/2/2016 – 10/18/2019

Registered Nurse

I worked on long-term follow-up of expert opinions for a medical technology company in a call center environment. Performed telephonic and computer follow-up with patients after receipt of an expert opinion, with the goal of ensuring that every patient received the highest level of care from highly qualified providers.

Specialty Health MCO, Reno, NV 8/2008 – 9/2014 and 10/2019 – 5/2020

Utilization Review Nurse/Quality Assurance/Case Manager

Performed high dollar prospective and retrospective inpatient and outpatient records review for medical necessity, standard of care, and coding

Responsible for outpatient, inpatient, surgical, DME, and medication reviews

Trained nursing and medical Utilization Review staff on evidence-based medicine guidelines

Researched and wrote appeal responses

Created and maintained over 900 macros on evidence-based medicine guidelines

Formulated a chart of accounts with client specific information for use by nurses and proofers

Performed ongoing Quality Improvement Projects requisite for URAC certification

One year as Telephonic Case Manager for large metropolitan police force

Audited over 900 hospital bills

Responsible for claim and hospital bill auditing

Responded to all appeals and attorney correspondence

J. Cowan, Medical-Legal Review, Reno, NV – 1995 – 2008, 2019 - 2020

Legal Nurse Consultant/Medical Reviewer

Review, synthesize, extrapolate, and summarize medical records for expert witnesses and attorneys

Review and analyze records for multiple disciplines

Preparation of chronological reports

Extrapolation of data from depositions

Formulate deposition questions upon review of medical records

Identify deviations from standard-of-care

Evaluate and render informed opinion on delivery of health care, outcome, and merit of claim with summary of findings

10/2013 completed review for class action lawsuit encompassing over 10,000 pages of medical records and 5,000 pages of depositions

9/2015 – 5/2016 completed review of over 54,000 pages of medical records and 3,000 pages of depositions with extrapolation of data and database entry, wrote summary opinion including opinion of merit of claim for 360 plaintiffs in class action lawsuit

Records review with formulation of deposition questions for plaintiff attorney

6/2016 – 1/2018 completed review of plaintiff and provider depositions with analysis and formulation of narrative summary as to whether depositions correlated with medical records

Sierra Nevada Cardiology Associates, Reno – NV – 10/2006 – 10/2007

Accounts Receivable

Clinical resource for an 18-employee department

Responsible for written appeals response on denied claims, including group health, Medicare, and workers’ compensation

Overturned 100% of 102 claim denials for one account

Promoted to Lead position

Genex, Las Vegas, NV – 10/2004 – 10/2006

Registered Nurse Field Case Manager

Collaborated with providers, employers and adjusters to ensure delivery of appropriate medical care and facilitate return-to-work post workers’ compensation injury and illness

Developed case management plan, adjusting in accordance with clinical status

Attended physician and hospital appointments/care conferences

Responsible for out-patient and in-patient facilitation of care

Washoe Health System - Hometown Health, reno, NV – 8/1999 – 10/2001

Utilization Review Nurse/Case Manager

Pre-certifications for concurrent and retrospective review for HMO, PPO, EPO, and Medicare products

Sole responsibility for writing procedural criteria for new technology coverage determinations

Prepared responses for medical and pharmacy appeals

Fitzgerald’s Gaming Corporation, Reno, NV – 9/1995 – 8/1999

Health Services Manager/Utilization Review/Case Manager

Responsible for establishment and oversight of employee health clinics for 3 properties

Ensured cost effective case management and delivery of care, OSHA compliance, training and certification of security staff on breath alcohol testing

Acted as company resource for FMLA and ADA adherence

Taught on-site EMT certification class

On-site case management for Reno, NV property and Telephonic Case Management for Mississippi, Colorado and Reno and Las Vegas, NV properties

Identify deviations from standard-of-care

Concurrent, prospective, retrospective hospital admission and emergency department review for group health pre-certifications for Reno, Las Vegas, Colorado, and Mississippi properties for this self-insured and self-administered group, utilizing Milliman and Robertson and McKesson/InterQual guidelines

Responsible for claim and hospital bill auditing

Responded to all appeals and attorney correspondence

Reviewed guest medical liability claims and corresponding medical records and prepared report of findings

Contributed to cost effective positioning of the company in alleged liability claims

Reviewed guest medical liability claims and corresponding medical records and prepared report of findings

Other Experience

RN Professional Recruiter/Senior Personnel Representative; Occupational Health Nurse in Aerospace manufacturing plant/financial institution, and hospital employee health; Hospital Infection Control Nurse; Medical Office Manager; Surgery Coder; Transcriber; Home Health Agency Nursing Supervisor; Hospital Assistant Director of Nursing; Hospital House Supervisor; Hospital RN in ICU, CCU, Surgical, Neurology, Urology, Orthopedics, Rehabilitation, Medical and, Endoscopy

Education

Registered Nurse – Lenox Hill Hospital School of Nursing – New York, NY

Laboratory Technician licensure – Eastern School for Physician\s Aides – New York, NY

Clinical Chemistry study – New York Community College – Brooklyn, NY

General Arts and Science – Hunter College, NY

School of Anesthesia for Nurse Anesthetists

- New York Medical College

Licenses and Certifications

Registered Nurse – Nevada RN16054

Certified Professional Utilization Review – CPUR – 9/2000 InterQual

Certified Managed Care Nurse – CMCN – 8/1999 American Association of Managed Care Nurses

Legal Nurse Consultant – LNC – 122/1995 Texas Institute for Legal Nurse Consulting, Vicky Milazzo

Certified Infection Control Nurse – 1979 - Centers for Disease Control

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