Karen Upton
Registered Nurse
Nolensville,TN
Summary
Dynamic, energetic, and self-motivated, professional nurse with extensive experience serving as an information systems clinical liaison; identifying and co-authoring program enhancements to improve proficiency in system operations. Accurately data mining, analyzing, and reporting clinical data with outstanding performance improvement recommendations utilizing Best Practices. Offering a complimentary skillset to include Medicare Advantage plan utilization review, care coordination and case management of complex cases, clinical audit, medical coding, quality and outcomes education. Proficient with accessing Medicare policy and regulatory resources,coverage determination policies. Providing more than 25 years of expert experience in home health. Highly organized, analytical, and hardworking, with excellent ability to project and effectively contribute towards process improvements.
Overview
32
32
years of professional experience
4
4
years of post-secondary education
2
2
Certifications
Work History
Care Manager II
MyNEXUS
Brentwood, TN
09.2017 - Current
- Perform pre-certification, certification, and/or authorization activities for all requested home health services that meet eligibility and benefits coverage
- Complete certification determinations
- Coordinate the submission of written authorizations to referring physicians and home health providers
- Collaboration and coordination with the plan member's servicing and ordering providers
- Case management and care coordination to identify and monitor the delivery of services is effective in meeting the plan member's total health needs, ensuring the highest quality of care is delivered, continuity in care is attained, and optimal outcomes are achieved in the most cost-effective manner
Director of Coding Education and Compliance
NHC HomeCare Corporate
Murfreesboro, TN
01.2006 - 08.2017
- Managed offsite professional clinical home health coders and the coding efforts of 36 remote agency level clerical coders
- Maintained a daily coding quota with audit of OASIS and comprehensive assessment in concert with plan of care, medical records, for accurate application of ICD-10 codes
- Managed, monitored, and educated staff on the internet-based OASIS Analyzing software
- Authored and hosted software, medical coding, and OASIS educational webinars and teleconferences
- Conducted data mining, analysis, and reporting with recommendations to senior level management
- Enhanced regulatory, strategic and operational performance to keep in alignment with deadlines
- Managed quality programs to reduce overdue compliance activities.
- Implemented improvement initiatives and developed compliance testing program to monitor and identify gaps in new and existing practices
- Established and cultivated productive relationships with regulatory bodies
- Drove system improvement efforts from concept to completion while strategically managing outside vendors
Clinical Computer Coordinator
NHC HomeCare Corporate
Murfreesboro, TN
02.2004 - 01.2006
- Managed multiple remote based Systems Trainers
- Home health clinical liaison to corporate information systems department, identifying opportunities for system enhancements and reporting system deficiencies
- Systems testing of newly developed and enhanced applications
- Training of clerical and clinical managers in systems applications related to payroll, billing, medical record processes, and web-based applications
- Responded to support requests from end users and patiently walked individuals through basic troubleshooting tasks.
Medical Audit and Coding
Various Coding Vendors
01.2010 - 04.2021
- Remote Contract coding and OASIS audit
- Reviewed outpatient records and interpreted documentation to identify diagnoses and procedures
- Updated patient financial information to guarantee accuracy
- Assigned appropriate medical codes with 97% percent accuracy rate
- Entered orders into EMR system efficiently and without errors
- Guarded against fraud and abuse by verifying coded data accurately reflected services provided
Customer Service Manager
Medical Bill Audit
Franklin, TN
01.2003 - 01.2004
- Supervised and directed the client services department and nurse coders
- Collaborated with marketing team and coordinated medical bill audits for more than 100 commercial payers
- Trained and mentored department staff on policies and procedures to establish strong foundation for client development and service activities
- Assumed ownership over team productivity and managed work flow to meet or exceed quality service goals
- Completed special projects by using effective decision making, critical thinking and time management skills
- Worked with marketing department to launch and manage promotional activities and campaigns
- Followed through with client requests to resolve problems
- Received, reviewed, and responded to customer complaints and implemented resolutions
- Resolved customer complaints while prioritizing customer satisfaction and loyalty
Regional Director of Operations
HealthEssentials
Louisville, KY
01.2001 - 01.2003
- Managed 20 house call practice nurse practitioners
- Managed 10 clerks, medical assistants, and physicians
- Program growth through community education and marketing
- Oversaw day-to-day production activities in accordance with business objectives
- Defined, implemented and revised operational policies and guidelines
- Provided documentation of processes to comply with regulations
- Monitored budget and utilized operational resources
- Evaluated performance, adjusted strategies and maintained agile, sustainable operations
- Monitored office workflow and administrative processes to keep operations running smoothly
- Kept up-to-date with industry trends and identified areas of opportunity to drive improvements
- Communicated with staff, patients and healthcare providers to encourage highest quality of service
- Assisted in recruiting, hiring and training of team members
- Trained and guided team members to maintain high productivity and performance metrics
Education
BSN - Nursing
The University of Tennessee At Chattanooga
Chattanooga, TN 08.2014 - 05.2016
Associate of Science - Nursing
Midway College
Midway, KY 08.1990 - 05.1992
Skills
4 years care coordination and management of complex and high utilization cases in Medicare Advantage Plan utilization reviewExpert proficiency in Microsoft, Teams, TeamViewer, DOS, UNIX, Documentum, Power Chart, NDoc, Devero, and Homecare Homebase, CitrixExpert clinical audit skillsExcellent data analysis skills and reporting skillsExpert understanding and proficiency in accessing CMS and managed care regulatory resources and guidelinesExtensive experience and outstanding ability to teach and develop professional quality educational materials, presentations, and teaching aides
Case assessments
Medical chart documentation
Staff Management
Wellness services
Hiring and recruitment
Relationship building and retention
Project oversight
Team Building
Patient education and counseling
Drug utilization review
Training and mentoring
Multidisciplinary team collaboration
Accomplishments
2011 Presenter at Home Health Coding Summit
Certification
Homecare Coding Specialist-Diagnosis, August 2021-August 2022
Timeline
Certified Case Manager, April 2021 - April 2026
04-2021
Care Manager II
MyNEXUS
09.2017 - Current
BSN - Nursing
The University of Tennessee At Chattanooga
08.2014 - 05.2016
Medical Audit and Coding
Various Coding Vendors
01.2010 - 04.2021
Homecare Coding Specialist-Diagnosis, August 2021-August 2022
02-2006
Director of Coding Education and Compliance
NHC HomeCare Corporate
01.2006 - 08.2017
Clinical Computer Coordinator
NHC HomeCare Corporate
02.2004 - 01.2006
Customer Service Manager
Medical Bill Audit
01.2003 - 01.2004
Regional Director of Operations
HealthEssentials
01.2001 - 01.2003
Associate of Science - Nursing
Midway College
08.1990 - 05.1992