Anna Lovekin
Nurse Consultant
Morrow,OH
Summary
Experienced Nurse Consultant with an extensive working history in the managed care industry. Knowledgeable about utilization management and appeals process from beginning to end. with an in-depth understanding of appeal process. Detail-oriented team player comfortable working remotely with strong organizational skills. Ability to handle multiple projects simultaneously with a high degree of accuracy.
Overview
23
23
years of professional experience
1
1
Certification
Work History
Nurse Consultant
Revecore
02.2020 - Current
- Perform analysis of clinical and claim records to validate services rendered for accuracy related to billing (EMR and scanned records)
- Interpret and apply utilization management guidelines (MCG, InterQual), benefit plan documents, and clinical policies to outpatient, inpatient, and behavioral health care claim denials.
- Research commercial and governmental payor policies, clinical abstracts and studies, and other documentation related to claims.
- Prepare and submit clinical and administrative appeals for medical, behavioral health, infusion, and pharmacy services on behalf of clients utilizing Microsoft Office and Adobe Acrobat products.
- Within the claim management process, research denials and denial trends and communicate findings to colleagues and clients for mitigation.
- Exceeded performance goals with recovery of over $9 million for clients during 3-year period.
Nurse Reviewer
HMS Permedion
08.2019 - 02.2020
- Perform retrospective clinical reviews for medical necessity and diagnosis/DRG validation.
- Identify documentation and quality of care issues for reporting, trending, and process improvement.
- Assist with developing training materials based on identified trends.
- Collaborate with clinical team to complete and deliver specific components of deliverables within contract guidelines.
Systems Engagement Specialist
CareSource
09.2018 - 08.2019
- Member of pilot team to develop multi-state and multiple market provider outreach program to increase cloud-based portal usage.
- Performed and participated in web-based training sessions with follow-up.
- Created written tools and processes for internal and external stakeholders.
- Designed strategic roadmap to guide team and business processes.
- Partnered with Medical Policy team to update and revise medical policies for automation of approvals.
- Assisted with UAT testing in multiple environments for quality and improvement.
Clinical Appeals Nurse-Community and State/Northeast
UnitedHealth Group
05.2017 - 09.2018
- Performed Standard and Expedited medical and administrative reviews for Provider and Member appeals utilizing MCG and InterQual guidelines and internal utilization management policy criteria.
Nurse Consultant (Owner)
E-Care, LLC
04.2008 - 08.2018
- Authored and conducted training programs for medical and non-medical clients.
- Supervised (80) client caregivers providing in-home care for seniors across two counties.
- Directed team of nurses conducting home visits in compliance with State and County requirements.
- Provided industry expertise to data analytics startup company in developing case management software utilizing predictive modeling and evidence-based data.
- Worked with CMS Medicare Bundled Payments for Care Improvement (BPCI) innovation program in startup phase for transitional care program.
Appeals Nurse
Anthem, Inc.
08.2016 - 05.2017
- Performed Standard and Expedited Member appeals for Medicare Advantage and Part D programs, utilizing National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs), MCG and InterQual guidelines and internal Utilization Management policy criteria.
Nurse Case Manager 2
Health Design Plus
07.2015 - 08.2016
- Conducted telephonic outreach, assessment, and care coordination for commercial members with medical and behavioral health issues.
- Utilized MCG to perform pre-certifications, pre-authorizations for DME, home health services, inpatient medical, ALOC and behavioral health admissions, per URAC standards.
- Partnered with Innovation team for discovery and configuration of Salesforce product for case management program.
Team Lead/Complex Case Manager, Case Management
Humana, Inc.
12.2011 - 03.2015
- Subject Matter Expert for case management process.
- Guided Members and Providers through Affordable Care Act (ACA) product implementation.
- Provided training and mentoring to new team members.
- Performed telephonic complex case management outreach for Ohio Market, addressing more complex post-discharge medical and psychosocial needs.
- Utilized MCG guidelines to perform authorizations for inpatient, post-acute services, durable medical, pharmacy, and outpatient services.
Nurse Case Manager
Venn Consulting
06.2001 - 12.2011
- Coordinated medical and rehabilitation services for Workers Compensation clients in Ohio, Kentucky, and Indiana, throughout the recovery continuum, from acute injury through return-to-work.
- Performed early intervention outreach to meet anticipated medical needs and minimize lost time.
Education
Certificate of Healthcare Informatics -
Northern Kentucky University
08.2021
Bachelor of Science in Nursing -
University of Cincinnati
Cincinnati, Ohio01.1988
Skills
- Utilization Review
- Case Management
- Appeals: Inpatient and Outpatient
- Evidence Based Guidelines
- Electronic Medical Records
- Clinical Operations
- Revenue Cycle Management
- Interprofessional Collaboration
- Analyzing documentation
- Case Documentation
- Clinical expertise
- Quality Improvement
Certification
- Registered Nurse, Ohio, active, 2023
- Certified Case Manager, active, 2028
Awards Recognitions
- 2012, 2013 Humana, Star Award (Customer Service)
- 2015 Humana, Process Improvement Program, Early Intervention in Catastrophic Health Events
References
Available upon Request
Timeline
Nurse Consultant
Revecore
02.2020 - Current
Nurse Reviewer
HMS Permedion
08.2019 - 02.2020
Systems Engagement Specialist
CareSource
09.2018 - 08.2019
Clinical Appeals Nurse-Community and State/Northeast
UnitedHealth Group
05.2017 - 09.2018
Appeals Nurse
Anthem, Inc.
08.2016 - 05.2017
Nurse Case Manager 2
Health Design Plus
07.2015 - 08.2016
Team Lead/Complex Case Manager, Case Management
Humana, Inc.
12.2011 - 03.2015
Nurse Consultant (Owner)
E-Care, LLC
04.2008 - 08.2018
Nurse Case Manager
Venn Consulting
06.2001 - 12.2011
Certificate of Healthcare Informatics -
Northern Kentucky University
Bachelor of Science in Nursing -
University of Cincinnati