Amanda Tolbert
Mansfield,AR
Summary
Compassionate healthcare professional with background in clinical nursing, known for high productivity and efficient task completion. Specialized in patient education, advanced practice regulatory knowledge, and evidence-based practice implementation. Excelling in communication, teamwork, and adaptability to rapidly changing environments to enhance patient care outcomes.
Overview
9
9
years of professional experience
Work History
Clinical Quality Audit Nurse
Ensemble Health Partners
Cincinnati, Ohio
03.2022 - Current
- Analyzed data from electronic health records to identify trends or patterns that may indicate a need for further investigation into potential discrepancies or errors in care delivery.
- Maintained patient records and verified patient privacy and clinical compliance to minimize data breaches.
- Read current literature and participated in professional organizations and conferences to keep abreast of nursing developments.
- Evaluated compliance with regulatory requirements in the provision of healthcare services.
- Identified areas for improvement in patient care processes through review of policies, procedures and protocols.
- Reviewed medical histories, laboratory results and diagnostic images for accuracy and completeness.
- Conducted clinical audits of medical records to assess quality, accuracy and completeness of documentation.
- Performed root cause analysis when investigating potential issues or errors within the healthcare system.
Clinical Denials Nurse
Ensemble Health Partners
Cincinnati
06.2019 - 03.2022
- Conducted quality assurance reviews of other Appeals Specialists' work product.
- Assisted claimants, providers and clients with problems or questions regarding claims.
- Worked closely with internal teams such as Medical Directors, Customer Service Representatives, and Provider Relations staff in order to facilitate successful resolution of appealed claims.
- Demonstrated ability to work independently as well as collaboratively within a team environment.
- Researched complex cases involving multiple parties or multiple issues to provide accurate decisions on appeals.
- Analyzed medical records to determine if further information was needed in order to process appeals.
- Developed processes and procedures for appealing denied claims that improved efficiency and effectiveness.
- Retained strong medical terminology understanding in effort to better comprehend procedures.
- Assisted in developing departmental goals as well as individual performance objectives.
Clinical Denials Nurse
Shared Services Center - Fort Smith
Fort Smith, AR
08.2018 - 05.2019
- Reviewed denied claims for potential resubmission or reconsideration.
- Collaborated with physicians, nurses, administrators, and other staff members to resolve issues quickly and efficiently.
- Tracked progress of ongoing appeals cases using computer software systems.
- Identified reasons behind denied claims and worked closely with insurance carriers to promote resolutions.
- Analyzed data related to denials, recoupments, adjustments to identify patterns or discrepancies.
- Maintained records of all appeal activities in a timely manner.
- Evaluated medical records to ensure accuracy of diagnoses and treatments.
- Investigated appeals to determine validity of claims and established appropriate action plans.
Admitting Nurse
Mercy Hospital Fort Smith
Fort Smith, Arkansas
08.2016 - 08.2018
- Called insurance companies to ascertain pertinent information regarding policies and payment benefits for patients.
- Liaised between physician, site of service and billing department to obtain appropriate documentation.
- Responded to patient inquiries regarding insurance coverage and billing issues.
- Determined estimated self-pay portion by calculating charges, co-insurance and deductibles.
- Instructed clients on amounts covered under benefits plans in easy-to-understand terminology.
- Adhered to HIPAA requirements to safeguard patient confidentiality.
- Contacted patients to confirm demographic information and communicate financial responsibilities.
- Managed daily workflow related to obtaining authorizations from various health plans including Medicare and Medicaid and commercial carriers.
- Monitored changes in insurance policies and guidelines to ensure compliance with prior authorization processes.
- Contacted insurance carriers to obtain authorizations, notifications and pre-certifications for patients.
Education
LPN -
Kiamichi Technology
Poteau, OK05-2008
Skills
- Nursing documentation
- Quality improvement
- Medical record review
- Clinical research
- HIPAA
- Audit management
- Clinical assessment
- Process improvements
- Audit preparation
Timeline
Clinical Quality Audit Nurse
Ensemble Health Partners
03.2022 - Current
Clinical Denials Nurse
Ensemble Health Partners
06.2019 - 03.2022
Clinical Denials Nurse
Shared Services Center - Fort Smith
08.2018 - 05.2019
Admitting Nurse
Mercy Hospital Fort Smith
08.2016 - 08.2018
LPN -
Kiamichi Technology