Medical Records Machine Learning
Resume:
Anastasia Nicole Cormier, LVN
**** ****** ********, ** ***** (c) 409-***-****
*********@*****.***
Professional Profile
Operations/Program Management License Vocational Nursing Medicare/Medicaid Regulations Revenue Cycle Management Investigative Medical Records Analytics/Auditing Data Mining and Reporting
Experienced healthcare professional with expertise in claim processing, and process management. Medicare and Medicaid compliance specialist. Sound analytic ability capable of process development and implementation, combined with an intellectual approach that promotes successful outcomes. With proven history of issue resolution, client integration, improving productivity, and increasing profit margins. Successful staff management including training and quality assessments.
Professional Experience
Texas Medical Board
May 2024 – Present
State agency that regulates medical licensure
Senior Investigator
Investigate complaints against Physicians and Physician Assistants
Collect evidence
Report to Medical Board on findings
Communicate with Complainants, Respondents, and all entities involved
Write subpoenas, affidavits, and other required documents
Categorize evidence
Apply Board rules and regulations to investigation
Perform Physician office inspections for rules and regulations
Must be accurate and organized
Work remotely
Lucina Analytics
August 2021 – December 2023
Analytics company data mining claims for early pregnancy Identification
Program Manager
Manage work from Proposal through completion
Process management
Validating outputs, creating dashboards (reporting)
Scrum Master - managing Sprint cycles.
Manage work inventory (Azure DevOps)
Claims management for use in identification and scoring of pregnancies
Using Medicaid regulations and 3rd party data
Machine learning / Data Mining Medical Claims
Creating reporting for all levels of Management
Equian/Optum
March 2018 – October 2020
Healthcare Payment Integrity Solutions Company, for Payers (Insurance)
Senior Data Analyst
Responsible for Claim review and recovery (includes resubmission)
Medicare, Medicaid compliance related to claims comparing to Medical Records
Analyze claim data (data mining) for payment accuracy
Reporting to Management and clients
Validation of contract matrices, and content, write up overpayments of claims in client systems
Creating queries and performing selection of claims (writing white papers)
Manage processes for client satisfaction and revenue recovery.
Reviewed Medical Records for Medical Necessity and continuity
Machine learning (AI)
Scio Health Analytic, Jacksonville FL
December 2008 - March 2018
Healthcare Payment Integrity Solutions Company, for Payers (Insurance)
Operations Manager / Subject Matter Expert
Responsible for Program Development and Management (Travel 20%)
Developed new business including implementation, audit processes and create models
Audit Medical records for Medical Necessity, continuity and billing practices
Interpreting data needs translating business needs to Data analyst query requirements.
Implementation new business and clients (2 programs that now gross over 1 million a month in revenue {Skilled Nursing and Home Health})
Build selection criteria to identify overpayments (data mining)/Inventory Management
Build Quality check processes
Reporting, internally & externally of findings
Managed up to 110 employees remotely and on-site
Hospital Corporation of America (HCA), Houston TX
October 2007 - September 2008
National Healthcare System
Regional Revenue Integrity Manager/Patient Access Director
Identified, Developed Process & Successfully brought Unbilled Claims from 5M(daily) to 500k(daily) through Coding Corrections.
Managed payment integrity and charge master for 5 Acute care facilities
Responsible for Management, Development and Training/Billing Accuracy (Travel minimum 10%)
Responsible for Clean Claims, Claim Edit Development/Resolutions, Coding and Code Mapping
Operational Development and training Protocol, Tool Development, System Enhancements, and Training
Creating reports for Corporate heads as well as facility Management
Responsible for Chargemaster accuracy and edits
National Audit (Scio Health Analytics), Jacksonville, FL
2006-2007
Healthcare Payment Integrity Solutions Company, for Payers
Hospital Bill Auditor
Collaborated Staff, and Facilities to Review Medical Records/Claims/Bills to ensure accurate billing.
Identified Claim Errors related to Coding
Audit (review) medical records for accuracy, continuity and Medical Necessity
Over a million dollars of recovery annually
JACCO Audits, China TX
2004-2006
Independent Contractor Clinical Audits
Collaborated with Internal Staff, Facilities to Review Medical Records/Claims/Bills to insure accurate billing.
Managed Time, Expenses, Schedule of Business
Audit Medical Records for Medical Necessity, continuity, and accuracy
Christus Healthcare of Southeast Texas, Port Arthur, TX
2000- 2004
Healthcare System (Regional Billing Office)
Audit Nurse/Chargemaster Manager
Completed Focused Audits by Department, Claim Coding, or Claim Edits
oFollowed by Education, Planning, and Implementation of any necessary changes
Completed Billing Compliance Reviews for Medicare, Medicaid, and Managed Care
oBased on Regulations and Trending reports
Implementation of New Processes to Increase Efficiency and Accuracy
Chargemaster Maintenance and Reviews, Executing Required Changes Related to Regulations
Review of contract and payment accuracy
Review of Rural Clinic/Hospital related to Rural Guidelines
Report of Findings/Trending/Planning to Executive Team
Floor Nursing
Baptist Hospital of Southeast Texas, Beaumont, TX
1996 – 2000
Hospital
Supervisor Inpatient / Outpatient Scheduling and Insurance validation
Created processes for seamless admissions including staff training
Scheduled all outpatient surgery and testing
oPre-Authorization as required
oConfirmed patient information etc. to prevent care delays
Inpatient screening
oDiagnosis verification
oPre-Authorization
Floor Nursing
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