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Click here or scroll down to respond to this candidateCandidate's Name , RN, BSN, MBAStreet Address
Mobile PHONE NUMBER AVAILABLE EMAIL AVAILABLEI am a seasoned clinical nurse who is self-motivated and demonstrates excellent listening, clinical and leadership skills. I am highly skilled in project management, disease management, and clinical education, chart auditing, marketing and presenting complex medical topics.
Professional ExperienceBlue Cross/Blue Shield/IllinoisJanuary 2019 to May 2019 (Contractor)February 2018 to May 2019 (Contractor)February 2017 to May 2017(Contractor)HEDIS REVIEW NURSE, OVER READER
Apply structured auditing criteria to abstract medical records from a variety of
EMR vendors, i.e. Epic, NextGen, QulfQuest, eClinical Works and Amazing charts. Follow defined procedures for saving approved medical record documentation and accurately enter
results of chart audits into database. Abstract medical records of documentation submitted for HEDIS measures. The HEDIS measuresare used to assist in measuring quality of health care provided to health plan members. Maintains productivity level with less than a 5% error rate in record abstraction and data entry on ongoing basis. Abstract data from Medicare Advantage Members.June 2017 to November 2017 (Contractor)RISK ADJUSTMENT REVIWER FOR CMS IVA PROJECT
Provider Network Relations, Health Care Management Retrieved medical records from providers with members enrolled in the Affordable Healthcare Act. Reviewed prior to sending completed medical records to the Centers for Medicare and Medicaid Services Initial Validation Audit (CMS IVA). Traveled to various provider sites to collect and abstract data. Uploaded medical records from the electronically collected medical records portal to the state reporting tool.
Audited over 200 medical records for CMS resubmissionDejean Wellness, Inc.
December 2014 to February 2017R. N. Consultant/Liaison
Coordinated and delivered education to patients with chronic diseases, such as: Multiple Sclerosis,Oncology, Cardiovascular as well as Diabetes, etc. Interacted with patients via telephone and in person to educate, motive, and empower during disease
Collaborated with physicians, staff nurses and office staff to assist with patient reimbursement programs, problem solving and seeks to assist patients with assessing resources from outside vendors.Blue Cross and Shield/ IllinoisJune 2015 to December 2015Appeals and Quality Specialist Processed first level appeals to appropriate medical vendors after denial from medical review units. Maintained BCBS clinical quality improvement projects to adhere to compliance with PCP/MG/IPA. Implemented clinical practice consulting with physicians, providers, members and vendors to assess, plan and facilitate special projects.
Strived to meet completion of appeals to 100 percent per month within a team approach.
Utilized CPT and ICD-9/10 codes to determine appropriate information to forward to outside vendors.Baxter Healthcare CorporationOctober 2008 to April 2014Benefits Administration Nurse Determination of medical appropriateness for Family Medical Leave Act. Review Return to Work Status. Obtained clarifications on medical certifications by contacting physicians/promoting relationships. Reduced stop loss of production of 15,000 employees by contacting physicians as to the estimated time away from work, needed to approve certification. Maintained medical data confidentiality; made timely decisions within HIPPA guidelines Lead for Quarterly Leave of Absence Conference Calls. Provide training to Human Resource Field Representatives on related medical processes: FMLA, GINA and
Coordinated with Workers Compensation Vendors.Additional Career SummaryBecton Dickerson-Per Diem - Clinical Nurse LiaisonMerck, Inc. - Senior Hospital Sales Cardiovascular, Infectious Disease and Diabetes SpecialistSeason Hospice and Palliative CareHospice Care Consultant -Manager Development ProgramLilly, Inc. - Senior Sales Oncology RepresentativeBayer Corporation - Senior Professional Infectious Disease and Cardiovascular Sales SpecialistEducationKeller Graduate School of Management, MBALewis University, BSN,
Register Nurse, Illinois |
