Earline Johnson

Responsible for review and evaluation of clinical information and documentation for Medicare providers services in Live Claims and the Special Investigation Unit (SIU). Reviews involve documentation and interpretation of data and observation of trends obtained via EHRs and various systems and applying clinical criteria to make appropriate determinations.
Execute company state and government policies such as the Centers for Medicare & Medicaid Services (CMS) policies and procedures such as National and Local Coverage determinations and Clinical Policy Bulletins in accordance with state
regulations and accreditation standards to align with the National Committee for Quality Assurance (NCQA). Independently coordinates the clinical resolution of complex cases with internal clinician support, such as in collaboration with Medical Directors and research of external resources

Proficient in navigation and application of Medicare Live Claims and SIU workflows, CMS National and Local coverage determination guidelines, Clinical Policy Bulletins, Microsoft, Excel, Encoder Pro, MedCompass, ATV, ASD, Microsoft, Rumba, Patient Management Referral, and other job-related software programs
Additional Accomplishments:

Crossed-trained in Medicare Live Claims, DRG, and SIU
Culture advocate member. Lead for Culture and Wellness channel for my team
Obtained Masters in Healthcare Administration

Management of Medicare second level appeal reviews. Clinical evaluation of electronic medical records for inpatient hospital admissions, inpatient rehabilitation stays, home infusion therapy, high cost drugs, durable medical equipment, diagnostic tests and ambulatory services where services were denied and appealed by the member or provider. Applying clinical data, company contracts, state and federal regulations and policies, and the Milliman Care Guidelines to make appropriate recommendations to uphold or overturn the denial.

Proficient in use and navigation of Centers for Medicare & Medicaid Services (CMS) polices and procedure guidelines, Milliman Care Guidelines, CATS, ATV, ASD, Microsoft, Rumba, Patient Management Referral, and other job-related software programs

Case Manager for the Aetna Retiree Health Access Program. Provided telephonic health risk assessments to members based on collected health data. Provided education regarding disease processes, healthcare management and available benefits. Advocated for the member to promote optimal outcomes while remaining cost-effective. Collaboration with internal and external stakeholders to ensure holistic care and continuity of care. Developed appropriate care plans based on member individual needs and commitment. Application of appropriate disease management assessment tools during scheduled HIPAA compliant outreach and follow-up phone calls to member and providers

Accomplishments

Participated in the pilot project and developed workflows for the Readmission Reduction program on my team
Received Case Management Certification 2013 (CCM)
Selected and received the Certificate of Achievement for Motivational Interviewing.

Nurse Consultant for the Long Term Care Options (LTCO) department for the Area Agency on Aging in Philadelphia, PA.

• Work involved evaluating the medical, social, and psychological needs and their effect on the functioning to offer services to improve quality of life to age well in their homes.
• Documented all case activities by state regulations, agency policies, and best practices by the Pennsylvania Department of Aging
• Assessed the need for emergency intervention and testified in court as needed.

Functioned independently as the team educator and medical consultant

• Co-managed LTCO team consisting of the team manager and up to 12 social workers
• Participated in orientation and training of new hires and conducted in-services with the rest of the department.
• Completed staff evaluations and annual performance measures