Felicia A. Harris
Rowlett,TX
Summary
Results-driven Revenue Utilization Review Nurse Consultant with expertise in utilization management and regulatory compliance. Increased revenue collections by 30% through data analysis and strategic leadership. Focused on improving patient outcomes and building collaborative healthcare teams.
Overview
25
25
years of professional experience
Work History
Revenue Utilization Review Nurse Consultant
VHA Centralized Business Office
Dallas, TX
07.2010 - Current
- Conducted clinical reviews for the purpose of pre-certification of admission, for outpatient or inpatient services, concurrent, discharge, retrospective, and appeals/denial reviews for approval from third party payers for services provided to Veterans.
- Applied advanced clinical knowledge and effective communication skills to perform clinical reviews efficiently and effectively.
- Collaborated with third party payors for authorization of service.
- Included scheduled/non-scheduled inpatient and outpatient levels of care (prescriptions, non- VA fee care, and or durable medical equipment).
- Served as a patient advocate and program liaison.
- Conducted focused reviews requiring clinical input for sensitive diagnosis, special consent issues, service-connected and special eligibility validation.
- Collaborated with clinical staff to provide education, back, and assistance regarding documentation of medical necessity, insurance review criteria, and Service Connections (SC) issues.
- Identified VA High Dollar Clinics previously unrecognized as billable, increasing revenue collection.
- Conducted Service Connection reviews using Quadramed and assisted with clinical reviews as directed by the CBO: i.e., The Combat Vet Project.
- Complete and obtained authorization for Health share Referral Management tool (HSRM).
- Communicated both orally and in writing to conduct clinical necessary to overturn denials and optimize reimbursement for the VA.
- Facilitated performance reviews.
- Collected, tracked, trended and analyzed appropriate data for reporting and performance improvement opportunities.
- Established mechanism for obtaining peer-to-peer reviews and provider documentation, enhancing revenue collection for insurance authorization and reimbursement.
- Revenue collections improved by 30%.
- Documentation requirements and ICD coding.
- Individual performs data validation of code assignment specific to type of care provided.
- Maintains current clinical knowledge to efficiently review medical records and perform documentation audits and identify opportunities for improvement.
- Reviewed for appropriate use of resources to meet admission criteria, (InterQual).
- Communicated with third-party payors for coordination of discharge.
- Empowered patients to make decisions that are in their best interest.
- Worked within a system of shared leadership.
- Oversaw continuum of patient care, linking patients with payors and staff to enhance patient outcomes.
- Used all hospital and community resources to ensure that patient is on the road to recovery after they leave the hospital.
- Effectively reviewed medical charts to ensure that appropriateness of care and assigned DRG per Medicare guidelines.
- Ensured that Medicare guidelines were met for reimbursement.
- Assisted with the accuracy of this data related to Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) and Centers for Medicare and Medicaid (CMS) Core Measures and other quality initiatives.
- Collaborated with and provided education to Care Coordinators and clinical staff for JCAHO Core Measure and other clinical initiatives.
- Charged with implementing strategies to provide managed care services to Medicare beneficiaries and Medicaid recipients.
- Served as primary source of administrative support to ensure achievement of fiscal and budgetary goals and compliance with applicable government regulation laws and federal Medicare rules and regulation and state Medicaid rule and regulations.
- Verified eligibility- Check that the patient is covered under the health plan, and that this coverage is primary.
- Verify that the requested service is a covered benefit under the insurance contract.
- If it is a covered benefit, determine if it requires preauthorization.
- Gather clinical information needed to determine if criteria are met for this service.
- Review of clinical information to determine if it meets criteria for medical necessity, and level of care.
- Ensure guidelines are met; the requesting provider is notified of the approval.
- If guidelines are not met, it is sent to physician review.
- Facilitated with Peer/Peer (P2P) with medical director collected more information and reviewed the case again.
- To allow medical direct to speak with the treating physician or send the information to an independent third-party physician with expertise in the specialty area of the request.
- Completed preadmission certification for patient services.
- Executed admission certification process for incoming patients.
- Conducted continued stay concurrent reviews for ongoing patient care.
- Performed retrospective reviews for second surgical options and discharge planning.
- Evaluated pharmacy therapy for patient safety and effectiveness.
- Management Review for Referral to Case Management Provides evidence-based Recommendations for level of care and evidence-based interventions based on InterQual coupled with reference to InterQual citations and other point of care resources
- Reviews medical records and accurately documents to ensure InterQual review process.
Assistant Nurse Manager (NON-VA Coordinated Care)
North Texas Healthcare System VA Medical Center
Dallas, TX
08.2011 - 03.2016
- Provide direct supervision of nursing and clerical staff support to service chiefs and other interdisciplinary team members in planning, designing, integrating, implementing, modifying, and evaluating the effectiveness of program components and services to improve the quality of patient care, appropriateness and timeliness of services provided.
- Participated in continuous quality improvement initiatives to enhance quality and continuity of healthcare services and optimize resource utilization.
- Collaborate with the interdisciplinary team to aid in the improvement of non-VA care coordination.
- Performance Improvement tool to foster quality improvements.
- Implement evidence base practices and knowledge that aid in overall program efficacy.
- Measure and evaluate staff productivity and outcomes related to non-fee care.
- Collaborate with team members to ensure success of fee program and VA mission.
- Makes program specific decisions that reflect the distinct and contributory role of nursing.
- Provide effective oral and written communication of pertinent data necessary for positive patient outcomes.
- Communicate with patients and staff for coordination of Veteran care.
- Conducted staff meetings to disseminate new information impacting the Fee Basis department and facilitate team alignment.
- Utilized CPRS, VISTA, and Microsoft programs to manage patient data and improve workflow efficiency.
- Integral part of the Community Care team that is comprised of MSA's, PSA's and facility nurses.
- Facilitate with implementation of Triwest and Choice Program.
- Serves as consultant on clinical issues, resource utilization and/or continuous improvement initiatives.
- Adhere to VHA policy and other regulatory guidelines necessary for providing quality for care for the Veteran population as the clinical expert perspective in the assessment of policies, projects, and data related to the measurement of quality, legislative, and administrative proposals.
- Ongoing consult management, coordination, prioritization and triage consult.
- Plan and conduct investigations/fact findings related to alleged or suspected violations of administrative policies/procedures related to Nursing.
- Lead in the management, monitoring, and oversight NVCC contractor transition activities; Evaluate the impact of transitions on NVCC customers and strives for continuous process improvements and responsiveness to customers' needs.
- Perform analyses of Non-VA Care (NVCC) operational policy and program operations to evaluate to appropriateness or other impacts resulting from the implementation of law, regulations, policy, or operational procedures and systems.
- Assessed and defined trends in NVCC operations policies and program operations, integrating the latest research findings into policy and operational analyses.
- Assessed educational needs and identified changing concepts of clients and technological advances; initiated and coordinated educational programs for specific populations and service levels.
- Identifies patterns and/or trends and ensures the identification of issues to modify and improve the program and to facilitate quality management goals and objectives accomplishment.
- Ensue and maintain quality care coordination for the NON-VA CARE program in compliance with regulatory bodies such as but not limited to Joint Commission, VA Program Offices, Office of Inspector General and other applicable entities.
- Assumes leadership role in fostering accountability in others for professional growth, for interpreting and observing policies/regulations, and for evaluating and improving patient care services within NVCC clinical review and consults case management programs.
- Triage Fee Unauthorized Clinical Eligibility – Mill bill Clinical Eligibility Authority to ensure appropriate reimbursement/clinical review for Non-VA CARE.
- Collaborate daily with Fee Department (Clinical appropriateness for NON-VA Care Versus Unauthorized care/claims).
Care Coordinator/Case Manager
Baylor Specialty Hospital
Dallas, TX
12.2008 - 08.2009
- Coordinated discharge planning by communicating effectively with third-party payors.
- Improved patient outcomes by overseeing the continuum of patient care and providing a link between patients, payor, and staff.
- Empowered patients to make decisions that are in their best interest.
- Collaborated within a shared leadership framework to enhance care coordination.
- Coordinated health care planning for patients.
- Streamlined approval processes for testing and hospitalization procedures, ensuring timely access to necessary care.
- Use all hospital and community resources to ensure that the patient is on the road to recovery after they leave the hospital.
- Provided patient education on treatment regimen, additional resources, and appeals processes.
- Promoted adherence to regimen to support wellness.
- Provided professional communication with patients or authorized patient representative on coverage and care plan.
- Collaborated with and provided education to Care Coordinators and clinical staff for JCAHO Core Measure and other clinical initiatives.
- Assisted with the accuracy of this data related to the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) and the Centers for Medicare and Medicaid (CMS) Core Measures and other quality initiatives.
- Reviewed for appropriate use of resources to meet admission criteria, (InterQual).
- Effectively reviewed medical charts to ensure that appropriateness of care and assigned DRG per Medicare guidelines.
- Ensured that Medicare guidelines were met for reimbursement.
- Compare the information to specific criteria to find support for the care request.
- Apply the appeal denial of payment for tests and services, utilization management (standard process for handling appeals).
- Plan participants to prevent unnecessary costs rather than restrict medical care.
- Perform statistical analyses comparing the costs of uncoordinated care with coordinated care.
- An activity known as concurrent review determines the medical necessity of tests and procedures during a hospital stay.
- This pre-certification activity reduces unnecessary inpatient admissions and decreases lengthy hospital stays.
- An activity known as concurrent review determines the medical necessity of tests and procedures during a hospital stay.
- Review veterans' medical claims to determine whether treatment is related to a service-connected condition.
- Bill third-party insurance companies for non-service-connected care.
- Coordinate benefits between the VA and other insurers, such as Medicare or private insurance.
- Review inpatient and outpatient episodes for billing accuracy.
- Ensure the VA receives reimbursement from private insurers when appropriate.
- Apply federal laws and VA regulations governing medical billing and collections.
Custom Complex Case Manager
United Health Care
Dallas, TX
02.2006 - 12.2008
- Conducted community outreach activities and conducted presentations for Medicare beneficiaries and stakeholder regarding the Medicare-risk contracting program, HIPAA.
- Maintained compliance with Medicare-risk contracting program rules and policies, ensuring effective operational management and quality assurance across member enrollment, customer services, claims processing, and appeals.
- Identified any gaps in health coverage, while coordinating services and resources for members.
- Supported members' care options based on patient's benefit plan.
- Developed individualized treatment care plans.
- Collaborated with Medical Director to evaluate and prepare justifications for appeals process.
- Communicated with United Health Care’s Medical Director for pre-certification and physician referral.
- Reviewed medical cases to determine appropriate hospitalization duration based on clinical documentation, facilitating timely patient care decisions.
- Identified items failing to meet policies and Milliman criteria.
- Utilized findings to make coverage determinations.
- Documented diagnosis, mitigating factors, relevant policy terms and provisions.
- Provided patient education on treatment regimen, additional resources, and appeals processes.
- Promoted adherence to regimen to support wellness.
- Coordinated and pre-planned health care services.
- Ensured medical necessity for tests and procedures to facilitate appropriate hospital admissions.
- Ensured that the services have a medical necessity and are provided at a customary and reasonable cost.
- A case reviewer determines the length of time a patient may stay in a hospital and have the costs covered by the plan.
- This pre-certification activity reduces unnecessary inpatient admissions and decreases lengthy hospital stays.
- An activity known as concurrent review determines the medical necessity of tests and procedures during a hospital stay.
- Perform statistical analyses comparing the costs of uncoordinated care with coordinated care.
- An activity known as concurrent review determines the medical necessity of tests and procedures during a hospital stay.
Medical Reviewer III
Blue-Cross/Blue Shield of Texas
Dallas, TX
06.2001 - 08.2003
- Performed accurate and timely reviews on medical claims submitted, medical necessity, Contract interpretation and pricing.
- Initiated responses to correspondence from the providers or the members concerning medical determination and issues.
- Communicated with Medical Directors for the appropriate case review and approval.
- Completed pre-certification and physician referrals, while reviewing medical cases for hospitalization authorization.
- Conducted medical record reviews necessary to make authorization determinations for healthcare services for beneficiaries.
- Reviewed diagnostic and treatment codes, applying Milliman and InterQual Guidelines with policy terms to authorize medical and behavioral care.
- Issued authorizations promptly to clients during service requests.
- Performed reviews of appeals cases handled by other departments for compliance.
- Verified all documentation and data for accuracy and completeness during reviews.
- Read justifications, analyzed mitigating factors, and applied precedent case to ensure consistency of determination.
- Identified high-risk cases and referred to Case Management Services.
- Worked with Medical Director to make determination for coverage outside normal parameter.
- Analyzed costs associated with care approvals and denials.
- Consistently achieved 98% on audits of routine and appeals determinations.
- Developed and coordinated care management plans, conducting ongoing service delivery reviews with primary care physicians.
- Managed transfers to inpatient, rehabilitation facilities, long-term, acute care facilities, and discharge needs.
- Coordinated home health, hospice services, reviewing documentation to ensure supportive of authorizations for coverage.
- Followed up to ensure service delivery and health monitoring and reporting of vitals or other required information.
- Serves as an expert in the development, evaluation, and implementation of policies related to Medicaid, Basic Health Program (BHP) policies.
Education
Bachelor of Science Degree - Nursing
University of Phoenix
Tempe, AZ05-2009
Associate of Science - Nursing
The University of State of New York
Albany, New York05-1998
Associate of Arts and Science -
Cedar Valley College
Lancaster, TX05-1994
Skills
- Utilization management
- Health care regulations
- Clinical documentation
- Healthcare policy expertise
- Regulatory compliance
- Data collection and analysis
- Leadership and management
- Change management
- Project planning and execution
- Process improvement
- Resource allocation
- Consultative skills
- Customer engagement initiatives
- Staff training and development
- Microsoft Office proficiency
- Outcome-oriented strategies
Personal Information
Title: BSN, RN
Committees
- Compliance Monitoring Committee, 2010 - present
- National Release of information Committee, 2010 - 2013
- Professional Standard Board of Nursing, 2011 - 2012
- Faith Community Nurse, 2018 - present
Licensures And Certifications
- Registered Nurse, Texas
- Basic Life Support for the Healthcare Provider
- LSS Yellow Belt, Green Belt & White Belt and Black Belt
Timeline
Assistant Nurse Manager (NON-VA Coordinated Care)
North Texas Healthcare System VA Medical Center
08.2011 - 03.2016
Revenue Utilization Review Nurse Consultant
VHA Centralized Business Office
07.2010 - Current
Care Coordinator/Case Manager
Baylor Specialty Hospital
12.2008 - 08.2009
Custom Complex Case Manager
United Health Care
02.2006 - 12.2008
Medical Reviewer III
Blue-Cross/Blue Shield of Texas
06.2001 - 08.2003
Bachelor of Science Degree - Nursing
University of Phoenix
Associate of Science - Nursing
The University of State of New York
Associate of Arts and Science -
Cedar Valley College