Anna C. Mountcastle
Raleigh,NC
Summary
Dedicated nurse with history of meeting company goals utilizing consistent and organized practices. Skilled in working under pressure and adapting to new situations and challenges to best enhance the organizational brand. Knowledgeable in evaluating medical records to determine accuracy and overall care quality. Experience includes review of medical records for both inpatient and outpatient needs with knowledge of medical terminology and team collaboration.
Overview
18
18
years of professional experience
Work History
Utilization Management Appeals Nurse Consultant
Aetna
Raleigh, NC
02.2018 - Current
- Work with providers and patients to assist with the appeal process for claim denials
- Review medical records in comparison with Milliman Care Guidelines (MCG) and clinical policy bulletins (CPB) to evaluate the necessity, appropriateness, and efficiency of medical care and procedures.
- Monitor care provided out of the network and assist in patients finding in-network providers
- Evaluate medical guidelines and benefit coverage to determine appropriateness of services.
- Evaluate charting procedures for adherence to best practices.
- Contact physician offices to obtain missing information from authorization requests as requested by medical director.
- Maintain confidentiality of client records to comply with HIPAA guidelines.
- Performed admission and discharge reviews based on medical necessity including diagnosis related group (DRG) hospital stays.
- Complete thorough review of medical records and present appropriate files and summaries to physicians or specialists for review.
- Meet with medical directors to discuss appeals and denials.
- Facilitate and present panel hearings comprised of patients and medical review experts to meet state mandates and standards.
- Participated in claims discussion meetings with claims examiners and supervisors to review complex claims.
- Input data into computer programs and filing systems.
- Maintained accuracy, completeness and security for medical records and health information.
- Communicated with physicians, nurses and other caregivers to explain importance of accurate and clear documentation.
- Contacted physicians regarding missing or unclear health record documentation and requested further information for clarification purposes.
- Processed records quickly to avoid delays and keep workflows running effectively.
- Verify the accuracy and overall completeness of medical records by auditing and reviewing patient information.
- Participate in continuing education surrounding medical terminology, diseases and conditions, and procedures.
- Submitted cases for criteria that are not met and help facilitate resolutions and approvals.
Registered Nurse Case Manager
Aetna Insurance
High Point, NC
06.2015 - 02.2018
- Managed care for pediatric, adult, and geriatric patients with various complex medical needs.
- Responded promptly and professionally to patient questions and concerns.
- Coordinated rehabilitative and preventive nursing processes and procedures.
- Telephonically assessed patients and documented history of current and previous conditions, diseases and injuries along with medications currently being taken.
- Completed initial assessments of patients and the family to determine and address individual care needs. ·
- Developed care plans based on nursing diagnosis and incorporated therapeutic, preventive and rehabilitative nursing methods.
- Evaluated healthcare needs, goals for treatment and available resources of each patient and connected to optimal providers and care.
- Created individualized care plans based on nursing diagnosis and incorporated appropriate nursing methods to achieve positive outcomes.
- Advocated for patients by communicating care preferences to practitioners, verifying interventions to help meet treatment goals, and identifying insurance coverage limitations.
- Conducted regular re-evaluations to address changes in needs and conditions, introducing revisions to care plans.
- Collaborated with other disciplines including medical directors, social workers, mental health specialists, utilization management nurses, and pharmacists, in order to identify patient needs to aid in achieving an optimal level of health and healing.
Clinical Nurse
Heart Center Observation Unit-WakeMed Hospital
Raleigh, NC
01.2008 - 06.2015
- Provided pre-procedure and post-procedure care for cardiac patients undergoing cardiac catheterization, cardiac stent placement, cardioversion, electrophysiology studies, pacemaker placement, insertion of automatic implantable cardioverter defibrillator (AICD), and percutaneous cardiac valve replacements.
- Closely monitored patients for cardiac arrhythmias and other life- threatening complications before and after procedure.
- Assessed patient conditions by performing thorough examinations and asking appropriate medical questions.
- Administered medications including intravenous medications and infusions.
- Performed clinical procedures using non-invasive monitoring equipment such as an electrocardiogram (ECG)
- Assisted in facilitating the recovery process through patient and family education with a focus on pre and post-operative procedures, prevention, medication, and pain management techniques
- Stayed current with health system initiatives and incorporated evidence-based practice and research into care routine.
- Used the Epic system to track patient status, treatments and outcomes while maintaining complete data confidentiality in compliance with HIPAA regulations.
- Functioned in the charge nurse role
- Questioned physicians regarding missing or unclear health record documentation and requested further information for clarification purposes.
- Collaborated with multidisciplinary team to evaluate patient data and determine patient care plans.
- Monitored patients, evaluated results and recommended further courses of treatment to quickly improve patient outcomes.
- Precepted new nurses following established standards of practice and organizational policies.
Seasonal HEDIS Clinical Documentation Review Nurse
Coventry Healthcare
Raleigh, NC
02.2014 - 06.2014
- Conducted utilization review and data collection using the HEDIS review system
- Collected data from patient charts and entered the data into a database system in order to measure patient and provider compliance related to core measures
- Performed regular quality and validation assessments on patient data to verify accuracy.
- Catalogued patient data in clinical databases and registries according to regulatory practices.
- Collected, organized, and entered medical data for physicians and patients.
- Studied and researched various medical terms as well as software systems.
Clinical Nurse
Neurovascular Surgical Unit WakeMed Hospital
Raleigh, NC
01.2005 - 01.2008
- Provided pre-procedure and post-procedure care for four to six neurovascular patients undergoing back surgery and brain surgery
- Performed total patient assessments on diverse patient populations
- Provided direct patient care, stabilized patients and determined next course of action.
- Provided care to stroke patients and assisted with the rehabilitation process
- Worked with patients and physicians to address problems and patient/family concerns
- Closely monitored patients for cardiac arrhythmias in the Neurological Step-Down unit and monitored patients for any acute neurological changes
- Managed care from admission to discharge.
- Worked collaboratively with the care team to discuss patient conditions and medical needs
- Served as a patient advocate to ensure that emotional and medical needs of the patient and family were met
- Helped to facilitate the recovery process through coordination of discharge planning in collaboration with physicians, case managers and social workers, nurses, nutritionists, and physical/occupational therapists
- Educated patients, families and caregivers on diagnosis and prognosis, treatment options, disease process and management and lifestyle options.
- Collaborated with physicians to quickly assess patients and deliver appropriate treatment while managing rapidly changing conditions.
- Precepted new nurses and functioned in the charge nurse role.
Education
Bachelor of Science - Nursing
East Carolina University
Greenville, North Carolina05.2005
Skills
- Patient Care Assessments
- Word Processing Software
- Benefits Guidelines
- Managing Diseases
- Utilization of MCG, InterQual, and CPBs
- Professional Communication
- DRG Patient Assignments and Hospital Admissions
- Health Information Systems (HIS)
- Medical Records Review and Accurate Documentation
- Eligibility Determinations along with insurance Billing and Requirements
- Conflict Resolution
- Appeals Support
Affiliations
Member of the American Nurses Association
Accomplishments
WakeMed Nursing Excellence award in 2008 and 2010
Timeline
Utilization Management Appeals Nurse Consultant
Aetna
02.2018 - Current
Registered Nurse Case Manager
Aetna Insurance
06.2015 - 02.2018
Seasonal HEDIS Clinical Documentation Review Nurse
Coventry Healthcare
02.2014 - 06.2014
Clinical Nurse
Heart Center Observation Unit-WakeMed Hospital
01.2008 - 06.2015
Clinical Nurse
Neurovascular Surgical Unit WakeMed Hospital
01.2005 - 01.2008
Bachelor of Science - Nursing
East Carolina University
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