Emily Copley
Ashville,Ohio
Summary
Healthcare Segment Specialist with extensive experience at Performant Corporation, excelling in regulatory compliance and cross-functional collaboration. Proven track record in leading complex initiatives that enhance claims integrity and reduce improper payments through data analytics. Adept at interpreting payer policies and fostering effective communication across teams.
Overview
15
15
years of professional experience
1
1
Certification
Work History
Healthcare Segment Specialist
Performant Corporation
08.2019 - Current
- Concept ideation/concept management CMS
- Program integrity- Collaborate with teams across the company to develop and maintain concepts for government programs
- Subject Matter Expert for Government/ CMS claims operations- DME specialty
- Manage inquiries related to appeals and RVC disputes
- Collaborate with internal teams, configuration and overall claims lifecycle
- Participate in CMS, MAC, and OIG meetings to ensure claim decision alignment.
- Responsible for identifying improper payments through data analytics
- Knowledge and expertise of claim regulatory requirements
- Provide leadership in complex, cross-functional initiatives focused on claims improvement
- Conducted regular meetings with staff to review progress and address any concerns.
Quality Assurance Auditor
Performant Corporation
07.2022 - 11.2023
- Reviewed completed audits within Performant to confirm audits were complete, accurate, consistent and adhered to regulations established by CMS
Medical Review Nurse
Performant Corporation
08.2019 - 07.2022
- Audited post pay claims for medical necessity, coding and documentation requirements-CMS
Inpatient Clinical Review Nurse
Concerto Healthcare
11.2018 - 07.2019
- Assessed clinical data from multiple sources including but not limited to medical records, lab results, radiology reports, medication administration records.
- Performed medical necessity reviews of inpatient services to ensure compliance with relevant regulations and standards.
Inpatient Clinical Review Nurse
Molina Healthcare of Ohio
04.2016 - 11.2018
- Review inpatient cases for medical necessity using MCG criteria
- Experience utilizing EPIC for inpatient clinical
Charge Nurse Surgical Services
Ohio Health Medical Center
Columbus, OH
01.2015 - 03.2016
Trauma/Emergency Department
Ohio Health Medical Center
Columbus, Ohio
09.2011 - 01.2015
Med Surg/Cardiovascular/Vascular Stepdown Unit
Ohio Health Medical Center
Columbus, Ohio
09.2010 - 09.2010
Education
Associate Degree - Nursing
OHIO UNIVERSITY
CHILLICOTHE, OH01.2009
Skills
- Lead SME for RAC Region 5
- Represent organization with CMS Division of Recovery Audit Operations (DRAO), Contracting Officer Representative (COR), Medicare Administrative Contractor (MAC), and Office of Inspector General (OIG)
- In-depth understanding of how claims data are reported and processed
- Experience researching and interpreting payer medical (coverage) policies (eg, LCDs, NCDs,)
- Regulatory compliance
- Cross-functional collaboration
- Medical necessity review
- Concept development
- Quality assurance
- Proficient in Microsoft products
Certification
Nursing License, Ohio Nursing Board, RN.356500, 12/31/09, 10/31/25
Timeline
Quality Assurance Auditor
Performant Corporation
07.2022 - 11.2023
Healthcare Segment Specialist
Performant Corporation
08.2019 - Current
Medical Review Nurse
Performant Corporation
08.2019 - 07.2022
Inpatient Clinical Review Nurse
Concerto Healthcare
11.2018 - 07.2019
Inpatient Clinical Review Nurse
Molina Healthcare of Ohio
04.2016 - 11.2018
Charge Nurse Surgical Services
Ohio Health Medical Center
01.2015 - 03.2016
Trauma/Emergency Department
Ohio Health Medical Center
09.2011 - 01.2015
Med Surg/Cardiovascular/Vascular Stepdown Unit
Ohio Health Medical Center
09.2010 - 09.2010
Associate Degree - Nursing
OHIO UNIVERSITY
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