Medical Review Records
Resume:
Candy Kuchar
DeForest, WI *****
************@***.***
Bachelor's Degree- Registered Nurse with exceptional time management and quality improvement skills. Striving to maintain and build confidence through collaboration, teamwork, and increased knowledge. I am interested in working in a team oriented environment with the common goal of cost effectiveness and quality outcomes while assisting in review of CMS/Federal/State regulations applied to Clinical Review. I enjoy a fast paced environment, working with others and finding creative ways to cut waste out of a process, teach others and constantly strive to improve. Knowledgeable in CMS regulations, billing/coding and Medical Review documentation audits. Provider Probe and Medicare prior Authorization expert. Authorized to work in the US for any employer
Work Experience
Clinical Supervisor/Medical Review Education
WPS Health Solutions-Madison, WI
June 2019 to Present
• Education development and training of all staff for Clinical Review based on CMS/LCD/ICD10/CPT codes and regulations to aid in training of RN staff in Medical Review
• Supervise Senior Nurse Analysts
• Creation of Educational materials for Medical providers/ Host Nationwide webinars
• Continuous Improvement of process development
• Collaboration with Medical Review Team/Medical Directors
• Provider outreach education conferences
• Development of Prior Authorization process per CMS regulations, LCD's, NCD's
• Quality Analysis of data daily
• Auditing of RN quality for Medical Claim review
• Reports for quality Improvement, function and planning
• Education of Medical Providers on CPT coding, regulations and correct clinical documentation. MCO RN Care Manager/ Medical Review
My Choice Care Wisconsin, Madison, Wis-Madison, WI June 2014 to August 2024
• Review of inpatient documents/effectiveness/quality care
• Utilization review,Medical records review for approval/denial. Appeals oversight. Attend Appeals hearings and write documentation related to appeal.
• Complex Case management of critically ill members with Medicare- Coordination with hospitals, specialists, suppliers of DME-DMS and future planning for the prevention of readmissions/accidental injuries
• Case Management and collaboration cross functional State/ Federal teams
• Medical Utilization Review
• Training of new employees
• Education of members and families regarding appeals
• Admission and discharge planning- DME
• State of Wisconsin LTC- certified
• Customer service to families and loved ones/problem solving
• Monitoring of medical records for MR, concurrent review Education
Bachelor of Science in Nursing
Marian University - Fond du Lac, WI
May 2012
Nursing Licenses
RN
Expires: February 2026
State: WI
Skills
• Quality Management (10+ years)
• Regulatory Compliance (6 years)
• Educational Content Development (10+ years)
• Supervising Experience (10+ years)
• Management Experience
• ISO 9001 (10+ years)
• Problem-solving
• ICD Coding (6 years)
• CPT Coding (6 years)
• Reliability
• Medical Coding (6 years)
• Internal Audits (10+ years)
• Content Management Systems
• Insurance Verification (6 years)
• Nursing (10+ years)
• ICD-10 (6 years)
• Analytics (10+ years)
• EMR Systems (10+ years)
• Project Management (10+ years)
• HIPAA (10+ years)
• Triage
• Medical Terminology (10+ years)
• Process Improvement (10+ years)
• Leadership (10+ years)
• Managed care (10+ years)
• Epic (10+ years)
• Quality Assurance (10+ years)
• Medical Records (10+ years)
• Program Management
• Employee Orientation (10+ years)
• Critical Care Experience
• Medical Billing (6 years)
• Case Management (10+ years)
• ICD-9 (6 years)
• Cerner
• Documentation review (10+ years)
• HCPCS (10+ years)
• Utilization review (10+ years)
• Utilization management (10+ years)
Certifications and Licenses
BLS Certification
ACLS Certification
Certified Case Manager
Assessments
Clinical judgment — Proficient
April 2020
Assessing a patient's condition and implementing the appropriate medical intervention. Full results: Proficient
Indeed Assessments provides skills tests that are not indicative of a license or certification, or continued development in any professional field.
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