Summary
Overview
Work History
Education
Skills
Certification
Accomplishments
Education
Timeline
Generic

Hilda Mbipeh Ghatenyui Epse

Sunnyvale,TX

Summary

Experienced clinical documentation improvement specialist with meticulous attention to detail and a strong background in the healthcare industry. Skilled in patient care, program management, and project development, with a focus on data analysis to enhance patient care quality. Proficient in conducting comprehensive chart reviews and providing actionable feedback to healthcare providers, as well as implementing effective documentation improvement strategies. Adept at identifying process enhancement opportunities and ensuring compliance with coding and billing regulations. Experienced in performing DRG validation reviews of medical records for accurate coding. Passionate and goal-oriented healthcare professional dedicated to delivering quality care and service to diverse stakeholders. Special expertise in educating, mentoring, and training healthcare workers for excellent customer service, safety, and quality control. Extensive experience in EMR implementation, project management, vendor operations, sales demonstrations, marketing, and product management. Also experienced in processing and adjudicating Durable Medical Equipment (DME) claims submitted by healthcare providers for accuracy, including verifying patient eligibility and determining appropriate reimbursement based on Medicare guidelines. Familiarity with certification and standards organizations. Holds a Master of Science degree in Information Systems Management, a Project Management Certification, and a Bachelor of Science in Nursing degree with over 18 years of experience.

Overview

15
15
years of professional experience
1
1
Certification

Work History

RN Clinical Appeals

Ensemble Health Partner
09.2024 - Current
  • Handles all appeals for clinically related claim denials at Ensemble Health Partners.
  • Supports analysis and review of records to avert future denials.
  • Provides clinical records to payers, and prepare for providers to provider (P2P) reviews.
  • Conducts claim analysis to determine appeal necessity.
  • Serves as liaison between healthcare providers to obtain additional medical documentation.
  • Facilitates communication between healthcare providers ensuring prompt processing of appeals.

Clinical Documentation Specialist/Information Spec

Texas Children Hospital
06.2022 - Current
  • Ensured compliance with relevant regulatory standards such as HIPAA through rigorous monitoring of electronic health information systems usage patterns.
  • Achieved a 20% reduction in documentation discrepancies and coding inaccuracies through comprehensive chart reviews, identifying documentation deficiencies, coding inaccuracies and compliance issues.
  • Collaborated with health care providers to offer education and feedback on documentation improvement.
  • Worked with interdisciplinary teams to implement CDI initiatives, resulting in a 25% reduction in compliance-related penalties.
  • Trained all members of the patient care team about documentation guidelines for medical records.
  • Analyzed data and prepared reports quickly and accurately
  • Prioritized multiple tasks met all deadlines and maintained productivity standards.
  • Improved patient care by implementing evidence based nursing informatics practices in daily workflows.
  • Managed electronic health records (EHR) and ensured the completeness and accuracy of patient data.
  • Collaborated with physicians, nurses and coding staff to clarify documentation discrepancies for over 500 patient records.
  • Assisted in transitioning from paper records to EHR systems, ensuring data integrity and compliance, resulting in a 25% reduction in administrative workload.
  • Contributed to hospital wide quality improvement initiatives by providing insights derived from data analysis and clinical informatics expertise.
  • Contributed to hospital-wide cost reduction initiatives by identifying opportunities for optimization within nursing informatics processes and technologies.
  • Developed and implemented tailored training programs for nursing staff on nursing informatics concepts, increasing competency levels within the department.
  • Provided consultation services for other departments seeking guidance on incorporating nursing informatics principles into their own processes and procedures.
  • Mentored junior colleagues in-developing their own nursing informatics skills, fostering interested a culture of continuous learning and professional growth within the department.
  • Served as a-liaison between nursing and IT departments,facilitating-effective communication and collaboration on various projects.
  • Optimized nursing workflows by identifying bottle necks and recommending appropriate health IT solutions.
  • Collaborated with IT professionals to develop user-friendly interfaces for clinical documentation systems, ensuring a smoother workflow for healthcare providers.
  • Streamlined communication between interdisciplinary teams through the use of advanced health IT systems.
  • Assisted in the development of standardized terminology-within EHRs, prompting -consistent documentation practices among healthcare providers.
  • Served as liaison between end-users and health IT team.
  • Applied medical subject matter knowledge to improve IT systems and functions.
  • Gathered data, information and workflow to develop evidence-based models for health information technology solutions.
  • Worked with product engineering team to define clinical requirements and assist with testing.
  • Consulted professional standards of care, scientific evidence and practice to evaluate health care programs.
  • Led, facilitated, and attended focus groups and meetings to strategize workflow issues.
  • Used advanced health informatics knowledge and judgment to promote colleague involvement in planning, decision-making and evaluating outcomes.

Manager of Audit and Appeals

Corewell Health
01.2024 - 09.2024
  • Led the daily operations and activities of the revenue cycle clinical appeals department and acts as a subject matter expert and resource to the team of clinical nurses, in addition to assuring continued growth, learning and accountability for outcomes within the department.
  • Acted as a resource and wrote appeals as needed to support the team and fluctuating volumes.
  • Prepared appeal letters and notifications to appropriate parties and hospital departments within the specified time frames and files appeal per contracted agreement.
  • Performs retrospective (post –discharge/ post-service) medical necessity reviews to determine appellate potential of clinical disputes/denials or those eligible for clinical review.
  • Produced reports to measure program results. Monitored KPI and lead initiatives to improve appeals rates.
  • Understood CMS medical necessity requirements and the coordination of care required under Federal and State regulations.
  • Assessed and developed concepts to improve denial management, documentation, and appeals process.
  • Ensured all clinical appeal efforts are documented in the appropriate electronic record.
  • Managed hiring activities, education and feedback for caregivers in the department. Participated in policy and procedure development and coordinate orientation and training of new associates.
  • Served as an educator and resource to the Care Management Staff, Physicians and other hospital disciplines as required/designated regarding Medicare, Medicaid and Commercial payer guidelines.
  • Ensured staff competency and conducted quality audits.
  • Coordinated material, lead and present and document staff meetings

Utilization Management Supervisor

Southwestern Health Resources
11.2022 - 12.2023
  • Devised innovative solutions to address gaps in care or inefficiencies within the utilization management process.
  • Supervised and coordinated activities of utilization review staff in maintenance of informed policy and procedure manuals, files, records and correspondence
  • Provided medical direction and drives quality and process improvement efforts for the functions and activities related to the authorization of eligible medical services, referral authorization activities, and referral authorization staff
  • Facilitated recruitment, selection, orientation and staff training, coaching and development
  • Led and directed the development, implementation, and evaluation of care management programs, policies and procedures and programs as part of annual strategic initiatives and reporting
  • Worked closely with the stakeholders to establish priorities, areas of concern and implementation plan
  • Managed and/or led project role assignments, prioritizing, and communicating to the team and stakeholders proactively
  • Actively engaged with the Management Leadership Team to define and measure goals for organizational/departmental performance and determines/develops the tasks and resources needed to attain them
  • Set clear expectations for team members, including defining what they should do on a daily and project level basis
  • Managed relationship and communication external stakeholders and health plans
  • Advised and coached team members by providing guidance on operational/project issues, key success factors of the project, and lessons learned
  • Provided Clinical Oversight for the Utilization Management Functions by evaluating effectiveness and determining the efficiency of ongoing projects in the workplace
  • Provided guidance on issues related to referral and authorization process, benefits interpretation, and other utilization issues

Utilization Review Team Lead/Clinical Auditor

Texas Children Hospital
07.2021 - 06.2022
  • Applied medical criteria and clinical judgement to researched cases to evaluate and establish determinations.
  • As assigned, investigates denied claims from insurance carriers and appeals timely to ensure accurate reimbursement.
  • Performed Data Analytics to determine aberrant providers needing review or investigation. Assess reports for patterns and trending of billing and coding patterns, over or under utilization, services outside scope of practice.
  • Queried physicians as needed to provide clarification on documentation or code assignment.
  • Assisted with developing policies and procedures related to coding.
  • Worked hand in hand with UM Manager to ensure the department is meeting client expectations and terms of contract requirements, State Laws/ Regulations, and NCQA guidelines.
  • Managed Work-queue as needed.
  • Followed Dashboard Reports to prevent compliance issues before they occur and early recognition of IS issues.
  • Monitored daily and monthly turn around times (TAT) to ensure compliance with contract requirements are met.
  • Monitored staff productivity.
  • Tracked 278 reports.
  • Served as resource to reviewers.
  • Assisted with training and managing OP notebook.
  • Documented monitored and developed training materials and training of departmental staff in utilization management guidelines and processes.
  • Adhered to accreditation, contractual and regulatory timeframe in performing all utilization management review.
  • Identified developed and implemented efficiencies in the workflow of the department.
  • Assisted UM manager with strategic goals.
  • Assisted UM manager to develop, create, and update UM policies and procedures to ensure compliance with Statements Laws/Regulations and NCQA guidelines.
  • Completed medical records review, accurately documenting findings and non-findings and providing clinical/policy/regulatory support for the determination.
  • Reviewed medical records to determine accuracy of billing through verification of coding and supporting clinical documentation.
  • Conducted audits to ensure accurate charge capture, enhancing reimbursement and identifying potential savings.
  • Reviewed medical reports and physician documentation for clinic and hospital outpatient services in order to apply diagnostic and procedural codes to individual patient health information for claims processing, data retrieval and analysis.
  • Demonstrated knowledge of, ICD-10-CM codes, PCS and DRG coding, understanding of payer rules and regulations, including Medicare and Medicaid with the ability to work independently with minimal supervision and demonstrate initiative.
  • Abled to clearly and accurately communicate findings.
  • Checked for physician's notes supporting the DRGs assigned.
  • Experienced using CMS website for correct coding, billing manuals, NCD/LCD, articles, and bulletins.
  • Up-to-date knowledge of healthcare regulatory, coding mandates and OIG work plan.
  • Assigned codes for ambulatory outpatient services using International Classification of Diseases (ICD) and Current Procedural Terminology (CPT) coding protocols, for facility and professional services.
  • Audited the electronic medical record for accuracy of patient information, insurance information, appropriate diagnosis, and procedure codes to ensure accurate documentation for billing and reimbursement.
  • Communicated with clinical department directors and medical billing staff to clarify coding guidelines and resolve claim edits.
  • Made recommendations or referrals if necessary to Special Investigations, Quality Assurance/Quality Improvement, Credentialing, Network Management . for further action if indicated.
  • Worked with Medical Directors to make recommendations for Medical Policy improvements, enhancements or updates to current medical policy language.
  • Maintained strict patient data procedure to comply with HIPAA laws and prevent information breeches.
  • Attended all other departmental meetings upon request of the supervisor, Manager or Director of care management.
  • Thoroughly complete documentation of daily activities regarding communication of members and clinical data to support MCG/Inpatient bed days
  • Provided information regarding UM requirements and operational procedures to members, providers and facilities.
  • Referred all requests that fail clinical review criteria to Physician advisor.
  • Identified and referred cases for inclusion in Holistic Health Management programs.
  • Utilized Medical Review Criteria, Medical Policy guidelines and internally developed review criteria to determine medical necessity, appropriateness of setting, including length of stay and type/duration of services.
  • Maintained knowledge of contract interpretation (Federal Employee Program, HMO) and containment measures (eligibility, extended care benefits and claims processing procedures).
  • Maintained complete confidentiality of company business.
  • Maintained communication with management regarding development within areas of assigned responsibilities and perform special projects as required or requested.
  • Complied with HIPPA, Diversity Principles, Corporate Integrity, Compliance Program policies and other applicable corporate and departmental business.
  • Maintained knowledge of current regulatory agency standards (TDI, AAHCC/URAC, NCQA) and adhere to regulations and corporate procedures

Clinical Nurse Manager

Standards Home Health
04.2021 - 07.2021
  • Ensured compliance with regulatory requirements by maintaining accurate documentation and adhering to established policies and procedures.
  • Developed strong relationships with patients'' families, addressing concerns and providing guidance on care plan implementation at home.
  • Maintained a safe working environment by enforcing infection control measures and adhering to safety protocols.
  • Implemented quality improvement initiatives to identify areas for potential enhancements in patient care delivery methods.
  • Assigned as a Remote RN Clinical Manager responsible for continuous review of all aspect of every patient on my caseload to include: appropriate utilization of services; ensuring continued skilled need; monitoring of homebound status; review of documentation in the medical record; maintenance of interdisciplinary communication and discharged planning.
  • Utilized the SHP system to coordinate review of Oasis documents for assessment of inconsistencies and collaborate with assessment RN’s on review. Made recommendation on plan of care and utilization of other disciplines to meet patient needs. Coordinated other discipline referral and ensures scheduling of evaluations.
  • Coordinated correction with QAPI team for their caseload and facilitated corrections, addendum and instruction of the staff.
  • Wrote/oversaw all orders and approved, then ensured scheduler schedules the new orders as applicable. Reviewed and co-signed LVN orders.
  • Reviewed all referrals for assigned area and approves for appropriateness for home health services.
  • Provided guidance and assistance to Field RN on Oasis accuracy and utilization of resources needed to meet patient outcomes of care according to State and Federal regulation and guidelines.
  • Ensured promotion of best practice for disease specific care.
  • Participated consistently in phone communication to collaborate care and participated in staff meetings.
  • Handled coordination of care to include OASIS comprehensive management; review all OASIS. Through collaboration and coordination, facilitated a plan of care that individualized and care planning to be a team effort to include patient and caregivers.
  • Obtained/maintained certifications in Oasis documentation at all times.
  • Collaborated with Billing Director/Coding team to ensure timely submission and completion of assessments, and completion of episode appropriate to request payment within established time frames.

Utilization Review Nurse/Implementation Specialist

Molina Healthcare
09.2019 - 04.2021
  • Provided EMR Practice and Clinical Training to doctors' offices and hospitals across the United States.
  • Conducted the Implementation process for sites, which includes In Depth Analysis reports, Kick-off Calls, Server Builds, Interface Set-ups and Training.
  • Implemented PrimePatient, patient portal to sites.
  • Demonstrated profound knowledge of workflow analysis, system build and functionality for each site.
  • Led development and implementation for training programs, including supervising projects that include multiple offices and locations.
  • Demonstrated familiarity with information systems implementation projects in both technical and non-technical roles.
  • Provided direct EMR user training and clinical support for offices and locations.
  • Collaborated with healthcare providers and members to promote quality member outcomes, to optimize member benefits, and to promote effective use of resources.
  • Performed utilization and concurrent reviews using Milliman criteria while auditing quality performance of practitioners and facilities to ensure safe practices while achieving productivity expectations.
  • Conducted clinical chart assessments and making critical decisions on appropriate levels of care while working with on-site case managers for structuring discharge planning and post-discharge services to prevent re-admits at Level-1 teaching hospital.
  • Demonstrated proficiency with both Care Planner and Care One
  • Conducted pre-certification, inpatient, retrospective, out of network and appropriateness of treatment setting reviews to ensure compliance with applicable criteria.
  • Applied clinical knowledge to work with facilities and providers for care coordination.
  • Worked with medical directors in interpreting appropriateness of care and accurate claims payment.
  • Determined appropriateness of treatment setting by utilizing the applicable medical policy and industry standards, accurately interpreting benefits.
  • Managed care products, and steering members to appropriate providers, programs or community resources.
  • Ensured member access to medically necessary, quality healthcare in cost-effective setting according to contract.
  • Demonstrated proficiency in electronic health record (HER) and Cerner.
  • Remain up-to-date on various benefits plans, medical policies and state-specific clinical guidelines or criteria
  • Current audit scores each quarter 100%.

Nurse Manager /Weekend Supervisoor

Brentwood HealthCare
09.2019 - 10.2020
  • Assigned as the Lead Nurse for long term care geriatric patients, delivering outstanding care to patients with various diagnoses and managed care from treatment initiation through to completion.
  • Oversaw nursing unit in long term SNF. Supervised 10 nurses and 15 nursing aids over 2 shift periods.
  • Conducted screening, diagnostic treatment and rehabilitative and supportive services as the senior nurse on a primary health care team.
  • Recorded patients’ medical history, vital statistics and test results in medical records.
  • Maintained patients’ charts and confidential files.
  • Led recruiting and hiring, managed employee review process and ensured compliance with state and federal regulations
  • Implemented infection control measures, resulting in reduced incidence of hospital-acquired infections.

Utilization Review Nurse

Pacific International Inc
03.2015 - 09.2019
  • Streamlined the case management process by effectively prioritizing high-risk cases for timely intervention and followup.
  • Served as liaison between Providers and Medical and Network Management Divisions
  • Determined contract eligibility and benefit coverage related to emergent referral requests.
  • Identified Providers contract status and provider network status including facility and Physician contract status
  • Conducted research and obtain medical information to complete the referral/certification request
  • Pended/completed certifications and/or referral authorization requests according to established policies and procedures.
  • Assessed all cases for quality of care and report quality care issues when identified.
  • Report members and provider complaints according to established policies and procedures.
  • Followed facility including checking in with designated facility personnel.
  • Maintained knowledge of clinical and technological advances in medical/surgical care, including pharmacological therapy.
  • Demonstrated working knowledge and familiarity with medical terminology.

ICU Nurse

Jamot Teaching /Psychiatry Hospital
06.2013 - 03.2015
  • Improved patient outcomes by implementing evidence-based nursing practices in the ICU setting.
  • Reduced ICU readmissions through thorough patient assessments and comprehensive discharge planning.
  • Provided life-saving interventions during emergency situations, stabilizing patients and preventing further complications.
  • Administered medications safely and effectively, following established protocols and guidelines for dosage calculations and administration techniques.
  • Coordinated timely responses to rapid response calls within the hospital facility leading to quicker intervention strategies for deteriorating patients.
  • Assisted in the orientation process of new staff members by providing guidance on unit policies, procedures, equipment usage.
  • Managed critical care patients with complex medical conditions, providing compassionate care and support to families.
  • Adhered to strict safety guidelines when handling and disposing of biohazardous materials to maintain a safe environment in the ICU.
  • Mentored new ICU nurses, sharing knowledge and expertise to enhance their professional growth and development.
  • Facilitated smooth patient transfers between units by collaborating with other healthcare professionals, ensuring continuity of care throughout the hospital stay.
  • Maintained strict adherence to infection control protocols, reducing hospital-acquired infections in the ICU setting.
  • Streamlined communication between healthcare providers, ensuring accurate information sharing for improved patient management.
  • Delivered age-appropriate medical care for adult, adolescent, and geriatric ICU patients.
  • Monitored patients' respiratory status and ventilator operation and made adjustments to promote stabilization.
  • Followed HCA ethical values and principles and adhered to HIPAA medical record regulations to promote patients' privacy.
  • Triaged patients and delegated treatment needs to qualified staff and specialized departments.
  • Conducted patient assessments, recorded vitals, and analyzed records and charts to define care requirements.

Junior Project Manager

Norvatis
03.2010 - 06.2013
  • Supported senior project managers in various aspects of project planning, execution, and closure activities.
  • Played a pivotal role in change management initiatives, assisting teams in adopting new tools or processes smoothly.
  • Managed project financials including P&L
  • Managed customer project delivery
  • Participated on and/or led multiple project teams as Project Manager
  • Understood quantity updating and worked with Superintendents to maintain accurate labor forecasts
  • Recommended changes to policies and established procedures that affect immediate organization(s)
  • Managed project financials including P&L
  • Fostered and maintained a collaborative professional working relationship with the Project Leadership Team
  • Assisted in preparing project presentations, participate and lead client presentations

Education

Masters Of Science - Management Information Systems

Institute Universitaire Siantou
Yaounde-Cameroon
06.2016

Bachelor Of Science - Biomedical Sciences

Cameroon Christian University
Bamenda-Cameroon
12.2014

Bachelor Of Science - Nursing

Cameroon Christian University
Bamenda-Cameroon
12.2014

Skills

  • Case management proficiency
  • Utilization Review Expertise
  • Prior Authorization
  • DRG Clinical Auditor
  • Demonstrated knowledge of ICD-10-CM codes, PCS and DRG coding
  • CPT coding
  • Clinical documentation review
  • Electronic Health Records (EHR)
  • Compliance and auditing
  • Interdisciplinary communication
  • Data analysis
  • Problem-solving
  • InterQual and Milliman criteria
  • Case Processing on Argus and Safety Easy
  • Microsoft Office Suite
  • Shared point
  • OASIS
  • Cerner
  • Care Planner
  • Care One
  • Medicare/Medicaid/Commercial
  • HCPC/ CPT/NDC
  • RxNorm
  • Telephone Triage
  • Management and Supervisory
  • Medical Terminology Familiarity
  • Healthcare Systems Understanding
  • Critical thinking abilities
  • Performance metrics analysis
  • Documentation accuracy
  • Process improvement strategies
  • Project management experience
  • Medical terminology knowledge
  • Budget Management
  • Facilities Maintenance
  • Administrative Management
  • Employee Supervision
  • Scheduling
  • Staff Management
  • Performance Management
  • Database Administration
  • Financial Reporting
  • Report Preparation
  • Attention to Detail
  • Written Communication
  • CRM Software
  • Data retrieval systems
  • Phone and Email Etiquette
  • Policy Implementation
  • Teamwork and Collaboration
  • Account Reconciliation
  • Policy and procedure modification
  • Interpersonal Communication
  • Reliability
  • Report Writing
  • Multitasking
  • Schedule Management
  • Operations Management
  • Quality Assurance
  • Time management abilities
  • Microsoft Office
  • Task Prioritization
  • Project Coordination
  • Root Cause Analysis
  • Leadership Development
  • Team Leadership
  • Administration and Operations
  • Presentation Design
  • Adaptability
  • Leadership and Change Management
  • Policy Development
  • Regulatory Compliance

Certification

  • Texas (Compact State) Registered Nurse License
  • New York Registered Professional Nurse License
  • California Board of Registered Nurse License ( in process)
  • Resource Utilization Group (RUG) Certification
  • Project Management Professional (PMP) Certification
  • SAFe Scrum Master (SSM) Certification
  • Basic Life Support (BLS) Certification

Accomplishments

    Team member for Epic Go-live at Texas Children Health Plan. I also served as touch point between my team and the epic technically team during my company Go-live.

Education

Bamenda-Cameroon,Bamenda-Cameroon,Yaounde-Cameroon

Timeline

RN Clinical Appeals

Ensemble Health Partner
09.2024 - Current

Manager of Audit and Appeals

Corewell Health
01.2024 - 09.2024

Utilization Management Supervisor

Southwestern Health Resources
11.2022 - 12.2023

Clinical Documentation Specialist/Information Spec

Texas Children Hospital
06.2022 - Current

Utilization Review Team Lead/Clinical Auditor

Texas Children Hospital
07.2021 - 06.2022

Clinical Nurse Manager

Standards Home Health
04.2021 - 07.2021

Utilization Review Nurse/Implementation Specialist

Molina Healthcare
09.2019 - 04.2021

Nurse Manager /Weekend Supervisoor

Brentwood HealthCare
09.2019 - 10.2020

Utilization Review Nurse

Pacific International Inc
03.2015 - 09.2019

ICU Nurse

Jamot Teaching /Psychiatry Hospital
06.2013 - 03.2015

Junior Project Manager

Norvatis
03.2010 - 06.2013

Masters Of Science - Management Information Systems

Institute Universitaire Siantou

Bachelor Of Science - Biomedical Sciences

Cameroon Christian University

Bachelor Of Science - Nursing

Cameroon Christian University

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