Experience

Buckeye Community Health Plan, Inc.

• manager prior authorization.

  • May 2015 - Present

  • Responsible for a team of 13 prior authorization nurses and 7 home health nurses.• Assist with obtaining approval from corporate to have CPT codes with a 5% denial rate or less resulting in them being removed from the prior authorization requirements for Buckeye. • Member of various company committees such as Policy & Procedure, Prior Authorization Guidelines, Authorization requirements, National Committee for Quality assurance (NCQA) for Prior authorization process.• Ensure completeness of authorization to meet State of Ohio Medicaid Health Plan requirements and National Committee for Quality Assurance requirements.• Participated in HSAG and NCQA audit review 2016 and 2017. Achieved NCQA Commendable level of accreditation in 2017.• Continuously monitored the staffing needs and assignments to ensure authorizations were completed timely• Decreased Turnaround Timeframes from 14 days to 10 days and exceeded expectations by reducing Timeframes to 5 days.• Worked with Senior Director of Utilization management to increase the price of DME equipment to a threshold of $1000.00 from $500.00• Currently creating a new home health work process• Currently creating a new home health audit tool to include NCQA requirements

• Lead appeals nurse

  • Jan 2014 - Present

  • Responsible for processing member appeals within 15 days.• Responsible for processing provider appeals within 30 days.• Responsible for reviewing the clinical records and determining medical necessity based off on Interqual criteria.• Member of the Medical Management sub-committee to report quarterly appeals data.• Responsible for gathering proper information regarding for completion of NCQA audits• Compiled charts for NCQA onsite review• Completed NCQA quarterly team audits.• Completed NCQA accreditation audits by presenting cases to NCQA auditors.

• Grievance and appeals

  • Jul 2007 - Present



Comp Management Assoc

• United States
• Insurance

• Appeals Alternative Dispute Resolution Unit Nurse

  • Jun 2004 - Jul 2007

  • Making sure level 1 review was received within 21 days by the Bureau or Workers compensation. • Processing Level 1,2, and 3 appeals • Processing claims to the appropriate physician • Sending decision letters and reviews to all parties • Sending level 3 appeals to the Bureau of Workers Compensation • Processed internal Comp Pain Management appeals • Staffing and coordinating claims with the assigned specialist and triage specialist • Making sure level 1 review was received within 21 days by the Bureau or Workers compensation. • Processing Level 1,2, and 3 appeals • Processing claims to the appropriate physician • Sending decision letters and reviews to all parties • Sending level 3 appeals to the Bureau of Workers Compensation • Processed internal Comp Pain Management appeals • Staffing and coordinating claims with the assigned specialist and triage specialist



Gates McDonald & Company

• United States
• Insurance

• Medical Only Nurse Alternative Dispute Resolution Peer Physician review coordinator appeals

  • Jan 1998 - Jun 2004

  • Managed medical only cases.• Monitored injured worker’s progress for return to full duty work.• Authorized treatment plans for injured workers.• Responsible for 12 delegated employers.• Assisted employers in claim reporting process • Responsible for mailing alternative dispute resolution packets to proper physician• Responsible for receipt of the level 1 reviews within 21 days to the Bureau of Workers Compensation• Made outbound phone calls to all parties involved with the claim• Notification of claims outcome to all parties involved in the claim.

• MCO Feel Bill Unit

  • 1997 - 1998