Experience

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  PRGX

  • Greater Milwaukee Area

  • Recovery Audit Nurse

    • Aug 2011 - Jan 2014
    • Greater Milwaukee Area

    • Performed Medicare inpatient first-level and second-level medical case review for recovery audit contractor.• Analyzed medical records to determine if providers are following CMS regulations.• Reviewed and determined case status as no findings or denied claims accordingly. • Maintain productivity standards and ensure audits are conducted within required time frames.

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  WellPoint

  • Greater Milwaukee Area

  • Medical Review Specialist

    • Jul 1987 - Apr 2011
    • Greater Milwaukee Area

    • Medicare medical review of outpatient, hospice, renal, and skilled nursing facility claims to determine medical necessity.• Analyzed medical records to determine if providers are following CMS regulations.• Approved for payment or deny claims accordingly.• Audit medical records to ensure compliance with billing documentation. • Maintained productivity standards and ensure audits are conducted within required time frames. • Coded and priced complex claims using ICD-9 and CPT manuals, where approvers are unable to assign codes with available data, or where no code exists.• Participated in training sessions for new providers encompassing Medicare rules and regulations, billing, forms, Waiver of Liability, and determinations of coverage decisions.

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  Family Hospital

  • Greater Milwaukee Area

  • Staff Registered Nurse

    • Jun 1980 - Jul 1987
    • Greater Milwaukee Area

    • Responsible for complete care of assigned patients. Worked in many areas of the hospital including intensive care, telemetry, geriatric, spinal cord, renal, psych, obstetrics, and all medical-surgical areas.• Wrote nursing care plans for patients and carried out the plan of care to help patients recover quickly and safely.• Taught patients and their families about diagnoses, treatments, medications, and self-care.• Supervised licensed practical nurses and nurse’s aides to assure quality patient care.