Experienced Per Diem School Nurse Candidate
Resume:
Claire E. Hughes MLS, BSN, RN, CPC
Westfield, New Jersey 07090
PHONE: 908-***-****
EMAIL: *********@*****.***
Well rounded professional as a Healthcare Compliance expert with an in-depth knowledge and experience in clinical nursing, compliance, quality, risk, auditing, consulting with strong business management background in financial analytics and project management. Highly customer focused with a demonstrated track record as an effective leader with strong communication skills. Professional Experiences:
NYU Langone Health, New York, New York
October 2012- Present
Patient Safety and Risk Manager (September 2021-Present)
Participate in system-wide hospital Risk Management program.
Coordinate with other clinical and administrative departments regarding risk management issues.
Provide direction and coordinate counsel to physician, nursing and administrative staff regarding medical-legal issues.
Monitor Risk Management cases and issues.
Participate in special projects and performs other related duties.
Identify issues for Quality Assessment and Improvement Quality Improvement and Standards Manager
FGP (Faculty Group Practice) Clinical Ambulatory Operations (November 2016-September 2021)
Registered Nurse team member that oversaw NYU Langone Health FGP (Faculty Group Practice) Ambulatory, new to NYU, existing, and Article 28 JCR Tracer sites. Concentrating on Survey Readiness for multiple Ambulatory Accreditations, Best Practices, Federal, State, New York City, and internal clinical operational compliance. Active interdisciplinary team member that investigated and supported FGP Regulatory oversite for patient safety intelligence (PSI) database and Root Cause Analysis (RCA) cases.
Clinical Charge Auditor (October 2012 – November 2016)
Audited both Concurrent & Retrospective accounts for charge capture opportunities and review documentation to identify discrepancies and recommend corrections.
Provided internal consulting to clinical departments to resolve compliance issues.
Responded to Managed Care, Commercial, and Governmental inquiries and denials and provide assistance in establishing responses and policies and procedures to adhere to all regulatory guidelines.
Responsible for generation of over 8 Million Dollars of recovered Denied claims during tenure
Recognized as the Finance Department, Employee of the Quarter, March 2015 Barnabas Health- Jersey Care Home Health, West Orange, New Jersey Clinical Supervisor (December 2009 –July 2012)
Managed 13 visiting nurses schedules and performance serving between 300-400 patients weekly covering Essex County, New Jersey
Reviewed and revised Clinical Policy and Procedure Manuals in accordance with federal, state and commercial insurance guidelines and provided staff in-service training regarding updates and changes.
Conducted remote reviews and assessments of staff’s clinical nursing documentation to ensure the timely and appropriate deliver of contracted services.
Performed onsite clinical performance reviews of employees. Evaluated for competency and completion of duties. Provided on-going counseling to improve both professional behavior and clinical techniques.
Horizon Blue Cross Blue Shield of New Jersey, Newark, New Jersey Medical Utilization Analyst (October 2006 - November 2009)
Conducted audit compliance reviews to identify provider outliers for possible fraudulent activity. Analyzed findings, created detail documentation and presented recommendations to legal for review and possible further action. Provided Legal Department with additional analytical support.
Evaluated internal reports to identify procedural miscoding, investigated findings, and recommended changes. Provided clients onsite and remote support to ensure resolutions. Horizon Casualty Services, Newark, New Jersey
Nurse Case Manager (December 2004 - October 2006)
Administered independently NJ State Workers Compensation case load consisting of 200+ clients and directly managed external relationships to resolve issues that were viewed as roadblocks in the successful supervision of the case.
CBIZ KA Consulting Services, Inc., Cranberry, New Jersey Nurse Consultant/Operational Manager (January 2001 - October 2004)
Provided consulting services to hospital systems and home care agencies in the area of medical necessity denials to identify and recover multimillion settlements such as a successful reduction of Medicare Review from 100% to 0% within six months.
Managed or functioned as a team member on multiple simultaneous consulting projects. Consistently met or exceeded target goals within specified timeframes.
Recognized as subject matter expert in the area of state and federal compliance standards and reimbursement criteria and as such provided on-going support and counsel to clients in regard to these guidelines. Functioned as an expert witness in the role of Clinical Nurse Auditor for the DOJ, Department of Justice. Fraud case settled for over $6M in favor of the DOJ. EDUCATION
Seton Hall Law School
Master of Legal Studies, Healthcare Law, January 2014 Healthcare Compliance Certification, Seton Hall Law, October 2011 Molloy University
Bachelor of Nursing Science
CURRENT PROFESSIONAL MEMBERSHIP & CERTIFICATIONS
American Heart Association, BCLS Certificate, Current American Academy of Certified Professional Coders, Morristown Chapter, CPC, Certified Professional Coder, Emeritus
Member of American Society of Healthcare Risk Management & Association for Healthcare Risk Management of New York
CLINICAL WORK HISTORY PROVIDED UPON REQUEST
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