Amy Noss RN, CCM, PMH-BC
Wernersville,PA
Summary
Focused Registered Nurse and Certified Case Manager with 30 years of combined experience in nursing, case management, and appeals management in insurance and various healthcare environments such as home health care, behavioral health care, and critical care. Expertise in all aspects of nursing, including assessments, treatment planning, medication administration, education, and utilization review. Demonstrated leadership skills with success in quickly establishing rapport with patients and working collaboratively with colleagues to achieve patient care and business goals. Seeking to apply strong clinical judgment and knowledge, as well as hands-on experience, to take next career step in a challenging position with a top-notch insurance agency.
Overview
21
21
years of professional experience
1
1
Certification
Work History
Appeals and Grievance Nurse Analyst
Healthfirst Insurance
09.2021 - Current
- Collaborated with cross-functional teams to gather necessary documentation and evidence to support the appeals process.
- Responded to attorney inquiries and litigation notices.
- Achieved successful appeal outcomes by meticulously reviewing and analyzing claim denials, identifying errors, and presenting persuasive arguments.
- Improved the appeals success rate by researching legal precedents and staying up-to-date with current industry regulations and guidelines.
- Consistently met or exceeded performance metrics, demonstrating a strong understanding of the claims review process and an unwavering commitment to achieving positive results for clients.
- Acted as a departmental resource on appeals matters.
- Expedited resolution times for appeals cases by efficiently managing workload and prioritizing urgent matters.
- Regularly received commendations from supervisors for demonstrating exceptional commitment to customer service and dedication to client satisfaction throughout the appeals process.
- Educated clients on their rights and responsibilities throughout the appeals process, ensuring a clear understanding of expectations and potential outcomes.
Registered Nurse Revenue Integrity
Tower Health
01.2021 - 09.2021
- Liaised between patients, insurance companies, and billing office.
- Reduced claim denials by diligently monitoring and addressing coding discrepancies.
- Served as liaison between clinical departments and finance teams, fostering effective communication and collaboration towards shared goals.
Case Management Outcomes Coordinator
Wellspan Ephrata Community Hospital
01.2020 - 01.2021
- Sustained quality standards by performing routine medication audits and upholding internal and industry best practices.
- Contributed to interdisciplinary team meetings by presenting relevant clinical data about patients'' progress toward reaching established goals of care.
- Observed and documented patient factors such as diets, physical activity levels, and behaviors to understand conditions and effectively modify treatment plans.
- Facilitated therapeutic communication, conflict resolution and crisis intervention by redirecting negative behaviors and helping patients regain or improve coping abilities.
- Educated patients, families and caregivers on diagnosis and prognosis, treatment options, disease process, and management and lifestyle options.
- Collaborated with interdisciplinary teams to develop comprehensive treatment plans for complex patients with multiple comorbidities.
- Advocated for patients by communicating care preferences to practitioners, verifying interventions met treatment goals and identifying insurance coverage limitations.
- Audited charts and reviewed clinical documents to verify accuracy.
- Participated in performance improvement projects aimed at streamlining processes related to utilization review and case management activities.
- Performed prior authorization review of services requiring notification.
Behavioral Health Complaint and Appeals Nurse Analyst
Aetna Life Insurance Company
01.2015 - 01.2021
- Achieved departmental goals and objectives by instituting new processes and standards for the behavioral health appeals process
- Participated in department Quality Assurance Program
- Prepared for HIPAA and JCAHO reviews
- Served as a liaison between members and insurance company to assist members in understanding their benefits and policies
- Identified needed behavioral health education training for members and made appropriate referrals
- Efficiently gathered information from available resources to make clinical determinations for required care concerning all inpatient levels of care as well as behavioral health medications.
Behavioral Health Appeals Supervisor
Aetna Life Insurance Company
07.2007 - 01.2014
- Oversaw all facets of case management and health appeals operations, including supervising medical support personnel and 12 health appeals staff, managing recruiting and hiring functions, handling employee review process, and ensuring compliance with state and federal regulatory requirements
- Developed, initiated, and maintained quality care systems and standards, including improved behavioral health appeals protocols and guidelines
- Instituted new processes and standards for customer care, resulting in achievement of department goals and objectives
- Prepared for HIPAA and JCAHO review, ensuring team members participated in required trainings.
Charge Nurse, Behavioral Health Unit
Ephrata Hospital
07.2003 - 07.2007
- Directed day-to-day unit operations activities during assigned shift, managing all aspects of care, ranging from medication management to emotional support, for 8 to 12 patients with various mental health and substance abuse diagnoses such as dementia, Alzheimer's, and addiction
- Accurately documented all elements of nursing assessment, including medical history, vital statistics, test results, treatment, medications, discharge instructions, and follow-up care
- Advocated patients needs and implemented total patient care through team nursing process
- Actively participated in unit-based Quality Assurance Program, continuously seeking opportunities to improve quality and delivery of patient care
- Educated patients on detox and withdrawal, medications, addiction, recovery, coping skills, and community resources, using customized teaching tools to maximize patient comprehension.
Education
Diploma - Nursing
Camden County College
Blackwood, NJRegistered Nurse -
Our Lady of Lourdes School of Nursing
Blackwood, NJSkills
- Direct and Indirect Patient Care
- Patient Education and Advocacy
- Case Management
- Care Planning
- Quality and Process Improvement
- Policy and Program Development
- Disease Management and Prevention
- Nurse Leadership and Unit Administration
- Complex Problem-Solving
- Documentation
- HIPAA Education
- Compassion and Empathy
- Clinical Documentation
- Critical Thinking
- Emotional Intelligence
- Patient and family advocacy
- Patient Care Oversight
- Coordinating referrals
- High level of autonomy
- Nursing staff leadership
- Patient care planning
Certification
Certified Case Manager, 2010, Current
Personal Information
Title: RN
Timeline
Appeals and Grievance Nurse Analyst
Healthfirst Insurance
09.2021 - Current
Registered Nurse Revenue Integrity
Tower Health
01.2021 - 09.2021
Case Management Outcomes Coordinator
Wellspan Ephrata Community Hospital
01.2020 - 01.2021
Behavioral Health Complaint and Appeals Nurse Analyst
Aetna Life Insurance Company
01.2015 - 01.2021
Behavioral Health Appeals Supervisor
Aetna Life Insurance Company
07.2007 - 01.2014
Charge Nurse, Behavioral Health Unit
Ephrata Hospital
07.2003 - 07.2007
Diploma - Nursing
Camden County College
Registered Nurse -
Our Lady of Lourdes School of Nursing
Certified Case Manager, 2010, Current
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