Barbara Biondo
Summerville,SC
Summary
Obtain a position that will utilize my investigative documented skills, abilities and experience to contribute to the Company’s success. Experienced in medical record review for fraud, waste and abuse utilizing professional research skills, multi-tasking, and detail oriented with a commitment to providing excellence.
Overview
38
38
years of professional experience
1
1
Certification
Work History
Clinical Fraud Investigator
Elevance Health
03.2019 - 07.2026
- Analyzed complex cases to identify potential patterns and trends in fraudulent activities in medical billing.
- Trained new hires and instructed other team members on investigative protocols and best practices to review outpatient data and medical records utilizing Commercial, Medicare, Medicaid rules and regulations, and coding CPT and HCPCS manuals.
- Prepared detailed reports summarizing findings, ensuring clarity for stakeholders and regulatory bodies.
- Worked with Investigators/team members in case reviews collaborating case information.
Medical Review Auditor
Piper Companies/Contract to Verscend
07.2018 - 10.2018
- Contract employees laid off; lack of work. Performed medical reviews of Medicare, Medicaid and Commercial claims for medical necessity, fraud, waste and abuse.
- 703-972-2092
Medical Reviewer/Analyst
Safeguard Services (SGS), LLC (Subsidiary to Perspecta)
02.2015 - 07.2018
- SGS, a NE UPIC Medicare contractor. Reviewed Medicare and Medicaid provider claims identified as outliers within the industry standard:
- Analyze claims for fraud, waste and abuse
- Make referrals to the QIO
- Prepare reports/Consultant Summaries
- Participate in provider onsite interviews as a member of the team
- Team work with investigators, data analyst, administrative aids and peers
Nurse Analyst/Appeal
Novitas, Inc. (Medicare Administrative Contractor (MAC))
05.2014 - 02.2015
- Novitas, a MAC, contracted to the Centers for Medicare & Medicaid Services.
- Review and reconcile denied appeals on first level of Medicare Appeals/Redetermination
- Review appeals and medical records, identify and reconsider claims to be paid utilizing additionally submitted documentation with Local Coverage Determinations, National Coverage Determinations, Articles and government rules, regulations and statutes
- Prepare reconciliation letters to providers
RN Medical Auditor/Revenue Recovery
MLECO and Associates
03.2002 - 08.2013
- Initiated new jobs both on site and remote, reviewed hospital claims/bills through medical record interpretation. Recovered tens of thousands of dollars in lost revenue for various providers in errors, defense audits or denied claims.
- Interpret and analyze hospital claims/bills utilizing medical records as contractor to various providers (Johns Hopkins, University of Maryland, AtlantiCare, Fredericksburg General Hospital, Northern Westchester Hospital, Mary Washington Hospital, Health South Hospital, etc.).
- Charge capture lost charges, identify errors in concurrent audits and defense audits for outliers.
- Prepared and analyzed audit results; prepared report summaries
- Reviewed, researched, data mine.
- Utilize nursing process and nursing theory skills in the audit process and certified medical audit skills.
- Wrote appeals for denied claims from insurers and government for various providers and reversed denials
- Knowledge of CPT, ICD-9 and HCPCS codes
- (Company has been dissolved-owners retired. Contact Jennifer Barker, Manager, Medical Auditors.)
RN – Travel Nurse
Avicenna Nursing Personnel, LLC
01.1999 - 01.2000
- As a traveling nurse I utilized nursing theory and skills to perform my nursing functions. Worked at community hospitals, state hospitals and teaching hospitals each in a variety of specialty units.
- Complete nursing shifts as needed – intervention and caring for patients
- Utilized electronic health record systems for accurate documentation and patient tracking.
- Instruct and teach CNAs and peers
- Flexible travel to various Maryland hospitals
- Delivered comprehensive patient care in diverse clinical settings across multiple states.
- Collaborated with interdisciplinary teams to develop and implement individualized care plans.
Registered Nurse – Staff position
Northwest Hospital Center
12.1988 - 12.1999
- Hired to work in Critical Care Unit and occasionally redirected to various department to fill open positions on occasion (i.e. Interventional radiology, ER, Progressive Coronary Care,and rehabilitation unit).
- Administered medications and monitored patient responses to ensure safety and effectiveness.
- Collaborated with interdisciplinary teams to develop and implement individualized care plans and discharge planning.
- Educated patients and families on disease management, medication usage, and health maintenance.
Education
Bachelor of Science Business Administration -
Kaplan University
Davenport, IA09.2014
Associates of Arts-Nursing - undefined
Community College of Baltimore-Essex
Baltimore, MD05.1984
Skills
- Medical record review
- Investigation and verification through research
- Utilize nursing process and nursing theory skills in the audit process
- Interpret, analyze medical records for fraud, waste and abuse
- Apply complex rules and regulations utilizing National Coverage Determinations, MAC Local Coverage Determinations and government statutes via Centers for Medicare and Medicaid Services (CMS) IOM manuals, Social Security Acts, Code of Federal Regulations (CFR), Commercial guidelines and addition practice standard documents
- Utilize coding books: ICD-9; ICD-10; HCPCS Level 1 (CPT) and HCPCS Level 2
- Detail oriented, research and in-depth data mining
- Excellent writing skills
- Training peers and customers
- Experienced nursing positions: ICU, CCU, PCU, medical, surgical, ER, community nursing, Home Health and Nursing Supervision, Rotating Charge Nurse
- In-depth knowledge of medical terminology
- Self-motivated and Home Office/Work at Home
- Work and travel independently and/or team work
- Proficient with PC application: MS office, PowerPoint, Outlook and Business Teams
- Knowledgeable in Excel
Certification
- Registered Nurse-Nursing License Compact-2024
- State of Maryland origination 1984
- American Academy of Professional Coders (AAPC) - Certified Professional Coder (CPC) renewal date: 05/2020
- AAPC - Certified Professional Medical Auditor (CPMA) -date 2023
Timeline
Clinical Fraud Investigator
Elevance Health
03.2019 - 07.2026
Medical Review Auditor
Piper Companies/Contract to Verscend
07.2018 - 10.2018
Medical Reviewer/Analyst
Safeguard Services (SGS), LLC (Subsidiary to Perspecta)
02.2015 - 07.2018
Nurse Analyst/Appeal
Novitas, Inc. (Medicare Administrative Contractor (MAC))
05.2014 - 02.2015
RN Medical Auditor/Revenue Recovery
MLECO and Associates
03.2002 - 08.2013
RN – Travel Nurse
Avicenna Nursing Personnel, LLC
01.1999 - 01.2000
Registered Nurse – Staff position
Northwest Hospital Center
12.1988 - 12.1999
Associates of Arts-Nursing - undefined
Community College of Baltimore-Essex
Bachelor of Science Business Administration -
Kaplan University
COMMUNITY SERVICE
Cross Keys Fellowship, New Hope Ministries