Elsa Olivera
Brandon,FL
Summary
Licensed Practical Nurse with over 25 years of experience and expertise in organizational and clinical quality and compliance. Excellent in medical review in conjunction with applicable criteria pertaining to review type and maintaining production and QA goals. Proven track record in implementation of internal clinical and quality management systems as a result of tracking trends and areas of improvement during audits and data analysis.
Overview
32
32
years of professional experience
1
1
Certification
Work History
Fraud Nurse Auditor
SafeGuard Services
06.2021 - Current
- Responsible for review of Medicare and Medicaid cases for Fraud, Waste, and Abuse utilizing Federal, CMS Medicare Administrative Contractor MAC policies, Standard of Care Guidelines, Including InterQual and Milliman Care Guidelines and/or State Medicaid Plan and Managed Care Organization (MCO) Policies
- Participate in coordination of the physician review process if required, after initial clinician review
- Responsible for conducting internal individual compliance audits, assigning daily quality control audits to sub-contractors, coordinate the review process with fraud investigators and provide feedback on cases under review
- Assisted with providing education/training and participate in management meetings/workload planning, as well as performing a final quality check and the end of medical review
- Promoted to Assistant Medicaid Medical Review Manager in Oct 2023-added responsibilities include assignment of cases to nursing staff and tracking for completion, staff resource to assist review staff with questions/guidance during reviews, Facilitate communication between investigative teams and nursing staff, assist with data analysis with investigative teams and attend meeting with CMS as needed
Care Management Program Auditor
Florida Blue Medicare
02.2020 - 05.2021
- Responsible for conducting monthly quality and NCQA compliance audits, targeted audits, coordinate and facilitate monthly quality meetings and developing educational materials for Complex Case Management, Readmission Prevention, Health Management Coaches and Community Health Staff, as well as assisting in developing audit metrics for each independent area of the Care Management program
- Assisted in developing Quality Improvement Programs (QIPs) to target trending issues found during monthly audits
- Coordinates and update desktop processes (DTPs) and Standard Operating Procedure (SOPs) on an annual basis, or more frequently, as needed
- Provides and coordinates training for new and current Case Management staff, including developing and facilitating training sessions
Utilization Management Nurse
United Health Group
05.2019 - 02.2020
- Post-acute care management nurse for UHG/Optum Responsibilities included determining the appropriateness of inpatient and outpatient services following evaluation of medical guidelines and benefit determination, specifically, the transition from the inpatient setting into skilled nursing, acute inpatient rehabilitation and Long-Term Acute Care Facilities using both Medicare criteria and Milliman criteria
- Required to identify solutions to non-standard requests and problems, translate concepts into practice, and act as a resource for others and helped provide explanations and information on difficult issues
Nurse, LPN
C2C Solutions
12.2011 - 05.2019
- Reviewer for the Medicare Qualified Independent Contractor for Part B-second level appeals Reviewed case files and supporting documentation submitted by Part B providers and beneficiaries; made decisions on coverage of medical services and procedures appropriate CPT, ICD, and HCPCS coding; and formulated decision letters using federal regulations including (but not limited to) CPT, ICD, and HCPCS manuals, the CMS Internet Only Manual (IOM), Local Coverage Determinations (LCD) and National Coverage Determinations (NCD)
- Elevated medical reviews to Contractor Medical Director (CMD), if needed
- Promoted to Quality Coordinator I in May 2017 Assisted with monthly quality and compliance audits, coordinated and facilitated monthly quality meetings with medical decision makers as well as management staff, and developed educational materials for decision making staff
- Supported International Organization for Standardization (ISO) certification and CMS audits by interacting with the ISO auditors and CMS staff when surveillance audits were conducted
- Also conducted and participated in mock ISO audits for the contract
- Coordinated and updated work instructions on an annual basis, or more frequently, as needed
- Provided and coordinated training for new and current staff, including developing and demonstrating presentations, quality tips, and decision consistency memos
- Coordinated and implemented an Inter-Reviewer Reliability (IRR) audit program and process that validated consistency among decision makers or identify areas of improvement
Field Case Manager
Centene Corporation
10.2012 - 01.2013
- Responsibilities included review of admissions through on-site and telephonic review for Medicaid beneficiaries to ensure medical necessity and appropriate level of care, review and audit of patient charts through on-site hospital visits
- Acted as clinical resource to referral staff and make appropriate referrals to complex disease case management and community agencies
- Provided patient as well as provider education
- Entered assessments, authorizations and reviews into the TruCare system
LPN Field Nurse
National Healthcare Review
03.2008 - 12.2011
- Concurrent reviewer for outpatient surgery, Emergency Department (ED) and inpatient accounts
- Ensure medical record documentation matches insurance billing, and adjust charges if changes are necessary
- Conducted utilization reviews using InterQual criteria as a contractor for local hospitals
- Conducted review process for Medicaid programs with Kepro and EQ Health
- Helped in Recovery Audit Contractor (RAC) appeal process for area hospitals
- Participated in and trained staff for insurance defense audits, managed care review and insurance appeals
Education
LPN Certificate - Licensed Practical Nursing
Miami Lakes Technical Education Center
Miami, FL12-1993
Skills
- Highly Skilled in Medicare Part A/B and State Medicaid regulations and all Centers for Medicare and Medicaid Services (CMS) levels of appeal, as well as the Medicaid rebuttal process
- Proficient in usage of National Comprehensive Cancer Network (NCCN) Guidelines, InterQual and Milliman Care guidelines
- Clinical experience in multiple areas including medical oncology, radiation oncology, and outpatient surgery (experience/employment information upon request)
- Proficient in Microsoft Office suite of applications
- Proficient in medical coding principles including use of Current Procedural Terminology (CPT), International Classification of Diseases (ICD-9 and10) and Healthcare Common Procedure Coding System (HCPCS)
Certification
- Certified Professional Coder (CPC) - American Academy of Professional Coders (AAPC), December 2023
Languages
Spanish
Native or Bilingual
Timeline
Fraud Nurse Auditor
SafeGuard Services
06.2021 - Current
Care Management Program Auditor
Florida Blue Medicare
02.2020 - 05.2021
Utilization Management Nurse
United Health Group
05.2019 - 02.2020
Field Case Manager
Centene Corporation
10.2012 - 01.2013
Nurse, LPN
C2C Solutions
12.2011 - 05.2019
LPN Field Nurse
National Healthcare Review
03.2008 - 12.2011
LPN Certificate - Licensed Practical Nursing
Miami Lakes Technical Education Center
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