Cheryl Smith
Corbin,USA
Summary
Dedicated and passionate registered nurse with over 10 years of experience delivering exceptional patient care across diverse healthcare settings. Expertise in collaborating with high-performing teams and fostering strong relationships through effective operations, account management, and strategic project oversight, particularly within the Commercial and Medicare sectors. Proven ability to communicate effectively and troubleshoot complex issues while making critical decisions under tight deadlines. Proficient in assessing needs, generating innovative solutions, and managing projects from initial requirements gathering to successful completion, all while maintaining a strong focus on consumer-centricity and maximizing productivity through AAPC coder certification.
Overview
18
18
years of professional experience
1
1
Certification
Work History
Clin Qlty LPN
Optum/United Healthcare Group
Minnetonka, MN
08.2025 - Current
- Completes supplemental data entry and primary source verification as directed, identifying trends and communicating accordingly.
- Maintains expert level understanding of the HEDIS /STAR measures and system processes
- Maintains productivity requirements for SDS and PSV with quality score of 96.5% or higher.
Remote HEDIS Abstractor
Advantmed
Irvine, CA
01.2025 - 05.2025
- Seasonal position remotely abstracting medical records, documenting in the HEDIS database, and maintaining 95% accuracy for HEDIS measures.
Utilization Management Nurse
Valenz Health
Phoenix, AZ
04.2024 - 05.2025
- Perform clinical audits on oncology, medications, inpatient, outpatient, physical therapy, occupational therapy, behavioral health and DME claims to make sure they are in compliance with NCCN and MCG guidelines, CMS and FDA criteria.
LPN
Lexington Clinic
Lexington, KY
10.2023 - 12.2024
- Administered medications and treatments per physician orders, ensuring patient safety and compliance with protocols.
- Assisted in rooming patients and helping with procedures based on patient assessments and medical histories.
- Educated patients and families on health management and medication use.
Clinical Quality Analyst Sr/Account Specialist
United HealthCare
Minneota, MN
03.2021 - 08.2023
- Responsible for 2.6M members in the Central Region for HEDIS Employer & Individual (E&I) Quality in 10 accreditation measures for 8 plans, coordinating strategy and collection operational tactics for 29K+ medical records with Market Quality Directors and 15 internal teams maximizing overall Stars health plan ratings.
- Facilitated and led market meetings to help drive collection strategy based upon plan and measure level goals set by market leaders, optimizing opportunities in driving overall rates.
- Participated in business partner and vendor meetings to review overall retrieval performance of 15 collection teams against service level agreements to maximize results across the health plans supported.
- Achieved membership in 3.5 Star plans with no 2.5 Star plans aligning with our North Star objective of 80% of plans in 3.5 Star and no 2.5 Star plans.
- Participated in initiatives and work groups that focused on improving processes and efficiencies to enhance collection opportunities.
- Minnetonka, MN
Remote HEDIS Abstractor
Altegra Health
Atlanta, GA
01.2017 - 03.2021
- Seasonal position remotely abstracting medical records, documenting in the HEDIS database, and maintaining 95% accuracy for HEDIS measures in Measure Group 1, which consists of Childhood Immunization Status (CIS), Immunizations for Adolescents (IMA) and Lead Screening in Children (LSC)
Nurse Auditor 2
Humana
Louisville, KY
09.2014 - 03.2021
- Audited/researched/reviewed high-cost medications for inpatient and outpatient facilities to ensure they were using medications in compliance with FDA and Humana Medical Coverage Policy Guidelines and correct coding guidelines.
- Perform clinical audits to ensure that medical record documentation and diagnosis coding for services rendered is complete, compliant and accurate to support optimal reimbursement.
- Developed, built, and researched to make new medication and medical policies for Humana to reduce savings for non-compliant procedures.
- Assisted fraud department with complaints by different physicians to reduce fraud throughout Humana.
- Accountable for organizing team/community sponsored activities to maintain relationships within Humana and for community of Louisville
LPN/Staff Nurse
BJM Staffing
Lexington, KY
11.2007 - 11.2015
- Travel to different facilities, performed duties in accordance with Kentucky LPN guidelines to include medication administration, inserting IV’s, drawing labs, performing EKGs.
Revenue Integrity Specialist/LPN
Baptist Health Lexington
Lexington, KY
08.2007 - 09.2014
- Performed chart reviews, prepared all relevant clinical information to obtain utilization review authorizations for outpatient oncology medications and IV infusion drugs for Baptist Health Lexington, Paducah and Richmond.
- Verified insurance, billing, and compliance coverage of appropriate chemotherapy treatments per Medicare and various insurance company guidelines.
- Verified claims via claims administrator to make sure labs/oncology/PET SCANS/IV infusion drugs were ready to be billed to appropriate insurance with correct diagnosis and codes to ensure the hospital was getting paid for the procedures.
- Wrote individual appeals for medical and pharmaceutical denials in accordance with FDA drug/medical guidelines.
- Scheduled, registered, and verified insurance information for patients for multiple tests and procedures performed at the hospital. Checked to make sure the compliant diagnosis is used for various hospital procedures.
Education
High School Diploma -
Fort Knox High School
Fort Knox, KYAssociate Degree - Nursing
Midway College
Midway, KY01.2011
Licensed Practice Nurse (LPN) -
Central Kentucky Technical College
Lexington, KY01.2002
Skills
- Microsoft Word
- Microsoft Excel
- Outlook
- Power Point
- OneNote
- Understanding of multiple claims and customer service databases and processes
Certification
AAPC Certified Coder
Skills Highlights
- Microsoft Word
- Microsoft Excel
- Microsoft Outlook
- Microsoft PowerPoint
- OneNote
- Understanding of multiple claims and customer service databases and process
Timeline
Clin Qlty LPN
Optum/United Healthcare Group
08.2025 - Current
Remote HEDIS Abstractor
Advantmed
01.2025 - 05.2025
Utilization Management Nurse
Valenz Health
04.2024 - 05.2025
LPN
Lexington Clinic
10.2023 - 12.2024
Clinical Quality Analyst Sr/Account Specialist
United HealthCare
03.2021 - 08.2023
Remote HEDIS Abstractor
Altegra Health
01.2017 - 03.2021
Nurse Auditor 2
Humana
09.2014 - 03.2021
LPN/Staff Nurse
BJM Staffing
11.2007 - 11.2015
Revenue Integrity Specialist/LPN
Baptist Health Lexington
08.2007 - 09.2014
Licensed Practice Nurse (LPN) -
Central Kentucky Technical College
High School Diploma -
Fort Knox High School
Associate Degree - Nursing
Midway College