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Click here or scroll down to respond to this candidateCandidate's Name , R.N.Street Address NE 15th Ave.Oakland Park, Florida Street Address
(P) PHONE NUMBER AVAILABLE(E) EMAIL AVAILABLECandidate's Name is a Registered Nurse with over 35 years of experience working in the field of healthcare. He holds a bachelors degree in nursing and a masters degree in Nursing Education and is a Certified Professional Coder through the AAPC. He has 20 years experience working directly with Medicare and Medicaid policies, regulations and compliance. His expertise is in clinical billing and coding review to identify potential fraud, waste and abuse. He has 15 years experience directly managing and supervising health care professionals at all levels. James is authorized to work in the US for any employer.Work ExperienceClinical Review ConsultantThe Justice Group Consulting, IncJuly 2019 to March 2021As a Medicaid subject matter expert, provide guidance on all clinical and compliance matters related to a Statewide Medicaid Managed Care (SMMC) Plan administered by a large private healthcare system. Responsibilities include but not limited to assisting in the development of data analytic algorithms to identify potential fraudulent billing patters among Medicaid providers. Development and implementation of policies and procedures for the Special Investigation Unit related to the governance of the medical review unit. Completion of medical review summaries as needed. Act as the primary resource for analysis of billing data from all Medicaid lines of business to identify potential investigative leads. Assist in the reporting of SIU actions to the appropriate state agencies.SEUPIC Medical Review ManagerSafeguard Services, LLCJanuary 2014 to March 2019Direct oversight and management all medical review activities for the Center for Medicare/Medicaid Services (CMS) Southeastern Unified Program Integrity Contractor (SEUPIC) task with identifying, investigating suspected or confirmed medical fraud, waste and abuse. Responsible for development of policies and procedures that support of the investigative teams actions through the review of medical and billing records from Medicare and Medicaid provider along all lines of business. Ensuring all PHI information is handled according to HIPAA standards. Development of policies and procedure for ensuring that all medical review documentation meets internal and external quality standards. Act as a subject matter expert on Federal Medicare and State Medicaid billing, coding, and documentation guidelines. Maintain a current understanding of all matters related to CMS Program Integrity directives.Case Manager/Utilization Review NurseHCA Aventura Medical CenterMay 2010 to December 2013Performed continuous assessments and evaluations to ensure patients progress towards desireddischarge criteria. Assess and respond to patient and family needs by coordinating efforts ofinterdisciplinary team members. Performed utilization review of all patients receiving Medicare and Medicaid employing Interqual Review and MCG Guidelines. Identify and resolve issues that hindered effective patient care.Hospice Telecare Manager (Per Diem)Vitas Innovative Hospice CareAugust 2008 to December 2010Managed and supervised a call center staffed by registered nurses responsible for providing triage, telephonic assessments, and advice to patients and family members regarding end-of-life care.Peer Review ManagerAetna Disability and Absence Management / Broadspire, Inc.August 2004 to Feb 2006; April 2008 to May 2010Managed the operations of the Physician Peer Review team in support of short term and long-term disability (STD / LTD) determinations. Acted as a resource for identifying clinical scenarios and assisted in determining appropriate clinical specialty for peer reviews. Developed and updated evidence-based tools and resources that enhance the defensibility of findings reports.Nursing InstructorFlorida State College at JacksonvilleDecember 2003 to August 2004Contracted faculty member responsible for providing classroom and clinical instruction to first year nursing students. Instructed students in issues relevant to professional nursing practice and provided clinical introduction of the student into the role of the nurse as a part of the health care.Utilization Review / Medical Review AnalystBlue Cross Blue Shield of Florida / First Coast Service OptionsMay 1996 to May 2003Analysis and review billing and clinical documentation to facilitate appropriate utilization of services for Medicare Part A&B beneficiaries. Developed Local Coverage Determination Policies (LCDs) to provide clear guidance to the provider community to support medical necessity and billing.EducationPeri-operative Nursing Certification 2010Palm Beach State College - Lake Worth, FLMaster of Science in Nursing 2000University of Phoenix - Jacksonville, FLBachelor of Science in Nursing 1990University of North Florida - Jacksonville, FLCertifications and LicensesRegistered Nurse, Florida License #RN2211232Certified Peri-operative NurseAmerican Academy of Professional Coders, Certified Professional Coder-CPC |
