RN

Amy Renee Ernst, RN, BSN, CMCN

513-***-**** *BEST TO TEXT*

*************@*****.***

Experienced professional Registered Nurse with strong leadership and relationship-building skills. A multitasking Physician liaison considered highly ambitious and willing to meet or exceed monthly quotas. My preferred background is working in Utilization Review & Insurance Appeals; QIO Appeals & Revenue Cycle Management Appeals review. These reviews include ALL the following: Medicare, Medicaid, and Commercial Insurance for UM & Appeals.

***WILLING TO OBTAIN OUT OF STATE LICENCES & RELOCATE IF NECESSARY***

Previous systems used: McKesson, Compass/PEGA, FACETS, MACESS, On-demand (EOB system), RightFax, FileNet, WMDS, ECC, CS90, XCEL, WGS/CA Mainframe, Medisys, One-Content, and GPS. Most recently used: EPIC, Amisys, Macess, HRP (Health Rules Payer), TruCare, Zelius (Redcard), & Cactus. I am confident, knowledgeable and able to work in other software program after proper training completed.

Job Skills below ALL are MET:

Current OHIO RN license.

Bachelor’s degree in nursing field.

Minimum of 2 years experience in a regulated environment.

Minimum of 6 years nursing clinical experience.

Strong customer orientation, organizational, planning, and communication skills.

Working knowledge of insurance industry, medical coding (CPT/HCPCS/ICD-10), and overall claims process.

Knowledge of Medicare National Coverage Determinations, Local Coverage Determinations, with frequent use of both Interqual and MCG criteria.

Excellent time management skills, interpersonal and communications skills with nursing staff and all other health workers involved in the care of a member.

Ability to meet deadlines and manage multiple priorities using multiple software systems.

Effectively adapt and respond to complex, fast-paced, rapidly growing, and results-oriented environments.

Able to work in a dynamic, fast-paced team environment and to promote team concepts.

Excellent typing skills with substantial knowledge of Microsoft Office including Teams, SharePoint, Outlook, PowerPoint, Excel and Word, etc.

CERTIFICATIONS

Certified Managed Care Nurse (CMCN) ~ by the AAMCN, American Association of Managed Care Nurses.

EDUCATION

Indiana Wesleyan University, Bachelor of Science: Nursing

Kettering College Of Medical Arts (KCMA), Associates Degree: Nursing

D. Russell Lee (Butler Tech), LPN Diploma: Nursing

Cigna INC. ~Nurse Case Manager Senior Analyst *CONTRACT POSITION w/MINDLANCE*

March 2022 to May 2022

PRIMARY NURSE WORK RE: PRE - CONCURRENT - POST - TRANSFER REVIEWS FOR MEMBER'S TO/FROM IN LTACH, SNF (SKILLED NURSING FACILITIES) & IRF (INPATIENT REHAB FACILITY) USING MEDICARE GUIDELINES, MCG (FORMLY KNOWN AS MILLIMAN) AND INTERQUAL SOFTWARE.

Responsible for the effective and sufficient support of all Utilization Management activities to include review of inpatient medical services for medical necessity and appropriateness of setting according to established policies and compliance guidelines.

Uses an established set of criteria to evaluates and authorize the medical necessity of services.

Provide notification of decisions in accordance with compliance guidelines.

Coordinate with Medical Directors when services do not meet criteria or require additional review.

Participation in staff meetings, regular trainings and other collaborative meetings as appropriate.

Works with management team to achieve operational objectives and financial goals.

Supports teams across UM Department as needed.

Active participation and completion of all required trainings.

Adherence to regulatory and departmental timeframes for review of requests.

Meet/exceed department Turn Around time, daily established productivity goals, and service levels.

Proficient knowledge of policies and procedures, Medicare, HIPPA and NCQA standards.

Professional demeanor and the ability to work effectively within a team or independently.

Flexible with the ability to shift priorities when required.

Other duties as required.

Clearlink Partners LLC ~RN Appeals *CONTRACT POSITION*

March 2021 to January 2022

Minimum of 6 completed/closed appeals daily either contracted or non-contracted provider appeals. .

Use appropriate business metrics (e.g. case turnaround time, productivity) and applicable processes/tools to optimize decisions and clinical outcomes.

Consider, review and evaluate appeals in compliance with state and federally mandated turn-around-times and process requirements.

Conduct retrospective, for appropriateness of diagnostic procedures, inpatient stay, ambulatory services, emergency department visits, evaluation & management services, coding levels, etc.

Ensure that all necessary clinical information is available to allow for a full and fair review.

Prepare claims and case summary for MD review and appropriate decision.

Ensure rationales are appropriate and supported by guidelines in accordance with regulatory requirements.

Access and review various resources to support denial or overturn denial (i.e. MCG, Interqual, and EMTALA act).

Genex Services ~ Disability Nurse Case Manager

JANUARY 2019 to March 2021

70 cases per day is normal case load for each Case Manager.

oMust complete an average of 12-14 tasks per day along with completing any new cases and answering/reviewing all incoming emails which average 35-50 per day.

Classify quality of diagnoses, treatment plans, conformance with treatment plan and rate of recovery for injured/ill worker.

Communicate and coordinate benefits at the start and throughout the duration of disability.

Secure physician back up and consultation as needed to ensure all judgments are medically sound Handle administrative tasks for disability compensation and company procedures.

Serve as intermediary to interpret and educate the employee on his/her disability, and the treatment plan established by physician.

Explain Physician’s and Therapists instructions and answers any other medical questions the employee may have to facilitate his/her return to work.

Assess overall treatment plan to ensure best medical care while meeting state and other regulatory guidelines.

Research, assess, and make recommendations to alternative company resources to facilitate recovery.

Work with Disability Claims team and OHN to identify and develop transitional / modified duty based on medical limitations and functional abilities.

Assist in development of transitional work programs when necessary in effort to return employee to work.

Mercy Ensemble ~ Denials RN (Revenue Cycle Management) *CONTRACT POSITION*

AUGUST 2018 to OCTOBER 2018

Up to 20 appeal reviews completed for contracted providers. My primary responsibility was for queues Anthem, Aetna & CareSource.

Performs all appeals for clinically related claim denials that occur in Patient Financial Services.

Contact insurance plans to determine reasons claims were denied, analyzing the claims and determining if appeal is necessary, preparing the appeal materials.

Work closely with the Case Management Department and HIM Department.

Anthem ~ Medicare Appeals Nurse

MAY 2010 to MARCH 2017

Medicare Grievance & Appeals including a rotation for the QIO appeals team.

o4-6 daily closed appeals; this would include both 30-day & 7-day appeals and also 72-he expedited appeals.

Medicare Appeal reviews for both contracted & non-contracted providers.

o18-20 daily closed appeals.

Investigate and process medical necessity appeals requests from members and providers.

Conducts investigations and reviews of member and provider medical necessity appeals.

Reviews prospective, inpatient, or retrospective medical records of denied services for medical necessity.

Extrapolates and summarizes medical information for medical director, consultants and other external review.

Prepares recommendations to either uphold or deny appeal and forwards to Medical Director for approval.

Ensures that appeals and grievances are resolved timely to meet regulatory timeframes.

Documents and logs appeal/grievance information on relevant tracking systems and mainframe systems.

Anthem ~ Utilization Review Nurse

SEPTEMBER 2008 to MAY 2010

Commercial UM call-center 8AM to 4PM EST.

o25-35 daily reviews received by email, fax and incoming calls.

Assess the medical necessity of inpatient admissions, outpatient services, focused surgical and diagnostic procedures, out of network services, and appropriateness of treatment setting by utilizing the applicable medical policy and industry standards, accurately interpreting benefits and managed care products, and steering members to appropriate providers, programs or community resources.

Works with medical directors in interpreting appropriateness of care and accurate claims payment.

Conducts pre-certification, continued stay review, care coordination, or discharge planning for appropriateness of treatment setting reviews to ensure compliance with applicable criteria, medical policy, and member eligibility, benefits, and contracts.

Ensures member access to medical necessary, quality healthcare in a cost-effective setting according to contract.

Consult with clinical reviewers and/or medical directors to ensure medically appropriate, high quality, cost effective care throughout the medical management process.

Sheakley Unicomp ~ RN Nurse Case Manager

AUGUST 2007 to AUGUST 2008

120-140 claims/cases is a normal case load for each Case Manager.

oMust complete an all RED tasks per day in system along with completing any new cases and answering/reviewing all incoming emails which average up to 50 per day.

Collaborate on medical treatment requests and outcomes to achieve a successful return to work for injured workers in the state of Ohio.

Serves as a liaison between all parties involved in the worker's compensation claim, including doctors, the injured worker, the employer and the Ohio Bureau of Workers' Compensation assigned Agent.

Main focus on disability and medical management that will result in a timely and sustained return to work (RTW).

Maintains department productivity and quality measures.

Optum Inc. (United Health Care) ~ Risk Case Manager

MAY 2004 to JANUARY 2006

Ongoing case load could be just one call to member or kept for long-term case management. System would determine after set questions answered the level of risk each member would be at and along with nurse input.

Completes comprehensive assessments and develops a Care Plan utilizing clinical expertise to evaluate the member's need for alternative services.

Assesses short-term and long-term needs and establishes case management objectives.

Responsible to collaborate with healthcare providers and members to promote quality member outcomes, to optimize member benefits, and to promote effective use of resources.

Provides case management services to members with chronic or complex conditions including:

Proactively identifies members that may qualify for potential case management services.

Identifies, assesses and manages members per established criteria. Develops and implements a case management plan in collaboration with the member, caregiver, physician and/or other appropriate healthcare professionals to address the member needs.

Performs ongoing monitoring of the plan of care to evaluate effectiveness.

Documents care plan progress in information system. Evaluates effectiveness of the care plan and modifies as appropriate to reach optimal outcomes. Measures the effectiveness of interventions to determine case management outcomes.

RN / Hospice of Dayton / September 2002 to January 2004

RN / Kettering Hospital MSICU / April 2000 to September 2002

LPN / Kettering Hospital Med-Sur/ September 1996 to April 2000 ~ BECAME RN / TRANSFER***

LPN / Middletown Nursing Home / February 1996 to September 1996

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