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Click here or scroll down to respond to this candidateCandidate's Name
Street Address Pier DrRuskin, Florida Street Address
EMAIL AVAILABLEPHONE NUMBER AVAILABLEProfileMotivated healthcare professional with over 20 years at the Cleveland Clinic seeking remote position utilizing my extensive experience in case management, utilization review and insurance denials/appeals to optimize benefits for payors and well as payees.ExperienceCleveland Clinic Foundation, Cleveland OHDenials/Appeals Specialist 2017-2022Reviewed denials and performed chart review to assess appropriate next stepsEfficient and accountable: Personally responsible for an 80% overturn rate on the denialsSummarized complex denials and escalated to Physician Adviser team for considerationParticipated in weekly telephone conference with Physician Adviser team and payor to overturn denied casesManaged a variety of payor sources throughout the United StatesUtilization Management 2012-2017 Comprehensive chart review to determine appropriate level of care (LOC): Observation vs Inpatient Performed timely review of prospective, concurrent and retroactive records using evidence based guidelines Oriented new team members as well as provided on-going education and chart audits Proficient in MCG and Interqual criteriaCase ManagementDaily assessment of patients for post acute care needs and referrals to various levels of careCoordinated complex discharge planning to include multiple modes of transport across the United StatesWeekly care conferences with Medical Directors to discuss team collaboration and research projectsSummaryFunctioned as a collaborative and creative problem solver in all the above areas, demonstrating leadership and instrumental in conflict resolutionEducation/License/CertificationUniversity of Akron, Bachelors of Science in NursingNursing License, Registered Nurse, Ohio and FloridaThe Commission for Case Manager Certification, Certified Case Manager (CCM)REFERENCES AVAILABLE UPON REQUEST |
