Amanda Spalding
Prospect,KY
Summary
Dynamic leader with over seven years at Humana, mastering complex problem-solving and strategic thinking. Spearheaded clinical audit programs, achieving significant savings and 99.8% Audit accuracy. Skilled in implementing strategic initiatives that enhance productivity and efficiency.
Overview
18
18
years of professional experience
1
1
Certification
Work History
Manager, Clinical Audits
Humana
Louisville, KY
12.2016 - 04.2024
- Proven Payment Integrity and Clinical Validation Manager with 7 plus years of experience in Pe- and Post-pay and end to end medical record reviews.
- Exceeded or met an $8,000,000 to $14,000,000 annual savings goal.
- Experience with Pre/Post Pay and end to end Medicare Review processes.
- Create clinical audit programs that grew overpayment identification with Shared Services.
- Key player in rolling out Patient Driven Payment Methodology to Humana, including upper leadership.
- Led a team of 20 Nurse Clinical Coders to validate accuracy and payment utilizing CMS guidelines .
- Earned the Values Anchor Award in 2021 for outstanding leadership during COVID.
- Conducted deep-dives and root-cause analysis with nurses, vendors, finance and compliance identify refinements and improvements.
- Analyzed quality, overturn data, return on investment, implemented actionable items and reported to upper leadership.
- Improved provider and market understanding of programs, reduction in Grievance and Appeals and provider satisfaction.
- Cross-trained employees to maximize team agility and performance.
- Maximized performance by monitoring quality, key metrics and return on investment.
- Streamlined workflows by identifying bottlenecks in existing systems and implementing appropriate solutions.
Clinical Reimbursement Director
Signature Health Care
Louisville, KY
01.2015 - 12.2016
- Achieved quality and reimbursement goals through auditing, training and communication.
- Guided 15 clinical teams to achieve 100% State MDS Audit accuracy.
- Closely worked with Regional Team (Therapy, Nursing, Accounting and Oversight) through both travel and virtual means.
- Reported monthly results and root cause analysis to Vice President, Clinical Reimbursement.
- Onboarded and trained new hires.
Corporate Director, Clinical Reimbursement
Deseret Health Care
Bountiful, UT
09.2013 - 11.2015
- Collaborated with the ongoing updates of the companies clinical reimbursement software.
- Identified numerous areas of opportunity for improvement in both financial and quality performance.
- Supervised 3 Regional Reimbursement Directors.
- Provided on-site assistance during software roll-outs and during State and CMS audits.
Regional Director, Clinical Reimbursement
Extendicare Health And Rehab
Louisville, KY
04.2006 - 08.2013
- Ensured the accurate completion of the Minimum Data Set Process and subsequent billing.
- Exceeded or met financial goals.
- Collaborated with Clinical partners to verify that documentation was accurate and supported services and conditions that were billed.
- Achieved 100% on audits of my work auditing claims.
Education
Master of Nursing Science - Health Care Administration And Nursing Leadership
Spalding University
Louisville, KYBachelor of Nursing Science -
Spalding University
Louisville, KYSkills
- Verbal and written communication
- Claims adjudication
- Quality monitoring
- Decision-making
- Team building
- Project Management
- Change agent
- Strategic Thinker
Certification
Resident Assessment Coordinator - RAC-CT
Certified Professional Coder - CPC
Certified Nurse Executive - CNX
Timeline
Manager, Clinical Audits
Humana
12.2016 - 04.2024
Clinical Reimbursement Director
Signature Health Care
01.2015 - 12.2016
Corporate Director, Clinical Reimbursement
Deseret Health Care
09.2013 - 11.2015
Regional Director, Clinical Reimbursement
Extendicare Health And Rehab
04.2006 - 08.2013
Master of Nursing Science - Health Care Administration And Nursing Leadership
Spalding University
Bachelor of Nursing Science -
Spalding University