
Highly motivated and organized RN with clinical and coding training specializing in DRG and readmissions claim reviews. Experienced charge nurse in the ICU department and member of the MET team at Charleston Area Medical Center. Skilled in phase 1 and phase 2 DRG reviews as a Payment Integrity Clinician, contributing to projects like the Inpatient Facility Diagnosis Guidelines and neonatal respiratory distress initiatives. Dedicated to mentoring newly hired clinicians and conducting readmissions reviews for the Payment Integrity team.
Performed clinical/coding reviews for phase 1 and phase 2 prepay and postpay DRG and readmission claims. Implemented pre-payment and retrospective review processes for claims, ensuring compliance with industry and corporate standards. Served as a mentor for several clinicians and performed clinical review findings letter peer reviews. In October 2022, received the Silver Applause Award for efforts in applying gestational diabetes diagnosis codes that our team could apply to applicable neonatal claims that resulted in maximum savings. This finding resulted in a lookback of claims that pertained to the targeted diagnosis codes, which resulted in $252,207.86 savings for the payment integrity team. Participated in the lookback project of neonatal hypoglycemia claims despite being a new clinician with only a few weeks experience. Participated in another claim lookback project in 2023 for respiratory distress syndrome with two fellow clinicians that resulted in nearly 2 million dollars in savings outcome. Participated in the creation/implementation of the Inpatient Facility Diagnosis Guidelines for the PI Clinical team. Assisted with the testing for claimHub and claimDrop updates. Collaborated on the MDC-14 project to perform manual DRG reviews to test the accuracy of AI technology for adjustment thresholds in 2024. Began performing Readmission claim reviews in January 2025.