Experience

StrategicHealthSolutions

• United States
• Hospitals and Health Care
• 1 - 100 Employee

• Medical Review Supervisor

  • Nov 2010 - Present

  Strategic Health Solutions, LLC: (11/2010-current) Medical Review Supervisor (8/2014 - current) for the Medicare Supplemental Medical Review Contractor (SMRC) ⦁ Telecommuting Medical Review Project Supervisor ⦁ Supervise Medicare Medical Claims Review projects for the Centers for Medicare and Medicaid Services (CMS), assist in the development of training guidelines, provide ongoing reviewer coaching, perform Quality Assurance (QA) on reviewer claims ensuring quality standards of 98% accuracy monitor reviewer productivity to ensure weekly metrics are met, perform claims reviews for over/under utilization of services provided, and complete the final reports for CMS. ⦁ Provide Final determination letters to Providers ⦁ Participate in Provider Appeals during the Discussion/Education period provided after Medical Record Claims Review projects ⦁ Completed research on Home Health Medicaid regulations for a litigative case for the Department Of Justice (DOJ). ⦁ Updated research on Home Health regulations for a litigative case for the DOJ. ⦁ Supervisor / Reviewer on Magnetic Resonance Imaging (MRI) reviews from the Centers for Medicare and Medicaid (CMS) and Medicare Administrative Contractors (MACs). ⦁ Litigative Consultant Services and Expert Medical Review Team- Collectively our Litigative Consultant Services and Expert Medical Review teams consisted of professionals with many years of experience in medical review, coding, and statistical work. As a team member, I provided medical review expertise in support of the Department of Justice (DOJ) and Office of Inspector General (OIG) investigations. · Provided expert subject matter services for the DOJ in support of several cases involving the US v. a Home Health Care entity. Re-priced sample home health claims in order to understand the financial impact of changes identified during a record review · Provided subject matter expertise for a Litigative case for The Centers for Medicare and Medicaid (CMS).



Strategic Health Solutions

• Medical Review Nurse III

  • Aug 2013 - Aug 2014

  Medical Review Nurse III (8/2013- 8/2014)· Home Health Face to Face Study – Tasked with identifying if the documentation met the requirements of Home Health Face to Face. Provided one on one teaching and coaching for reviewers, conducted QA on claims reviews to ensure 98% accuracy, run claim detail reports to ensure claims accuracy, and assisted with resolution of impairments when identified · Home Health Medical Review Project- Key contributor- Created training guidelines, a checklist to assist reviewers, audit tool instructions, and tested the CMS payment system to ensure accuracy of payments for services billed· Assisted with research and development of medical review documents and performed QA on reviews for studies involving Therapy projects, Magnetic Resonance Imaging (MRI), and Single Photon Emission Computed Tomography (SPECT), created checklists and audit tool instructions, and performed QA · Provided teaching and coaching for reviewers for the Hyperbaric Oxygen Therapy (HBO) study, assigned claims, and performed QA on reviews to ensure 98% accuracy was met· OIG Nursing Home Monitor - Conducted on-site audits which included: company policies and procedures, wound treatment, care provided, documentation, educational training programs, and corporate oversight of policies. Interviewed staff members, observed medical care, observed care plan meetings with families, observed clinical start up meetings, and weight/wound meetings

• Medical Review Nurse II

  • Feb 2012 - Jul 2013

  Medical Review Nurse II (2/2012 - 7/2013)⦁ Completed Home Health reviews maintaining 98% accuracy⦁ Completed Power Mobility Device (PMD) reviews maintaining 98% accuracy· Conducted research and completed guidelines for Ambulance Transport for Dialysis Patients, Air Ambulance and Transthoracic Echocardiograms· Completed L7900 reviews · Completed Home Health reviews for a Medicare Administrative Contractor (MAC)

• Medical Research Analyst

  • Nov 2010 - Feb 2012

  Medical Research Analyst, R.N. (11/2010 - 2/2012)· Quality Improvement for Medicare Advantage (MA) & Special Needs Plans (SNP) · Created new reporting tools for Quality Improvement Projects (QIPs) and Chronic Care Improvement Programs (CCIPs) for the Centers for Medicare and Medicaid Services (CMS)· Developed criteria for the new reporting tools for QIPs and CCIPs · Created Standard Operating Procedures (SOPs) for CMS for pre-enrollment reporting tools, QIPs, and CCIPs · Created reference manuals, training materials, and slide presentation for QIPs and CCIPs for CMS and the MA Plans