Karen Brey
Port Washington,WI
Summary
Dynamic RN with extensive experience at Elevance/Anthem/National Government Services, excelling in Medicare medical necessity reviews and care management. Demonstrated clinical judgment and compassion, reducing hospital readmissions through effective discharge planning and patient education. Proficient in EMR systems, Microsoft, Excel, ensuring quality improvement and optimal patient outcomes in complex cases.
Overview
31
31
years of professional experience
Work History
RN Medical Management II
Elevance/Anthem
06.1999 - 07.2023
- 2019-2023 Anthem Medicare Part C medical necessity review of ER admissions that converted to inpatient admissions. The review focused on the appropriateness of inpatient stays versus Observation status. The position also included care management and discharge planning functions.
- 2016-2019 National Government Services Medicare fee for service Part A and Part B. Quality Auditor Medical Review. Auditing documentation to ensure correct decisions were made and Medicare rules and guidelines. coverage determinations were utilized correctly
- 2008-2016 National Government Services Medicare Part B Medical Review. Reviewed Part B provider medical records to ensure correct billing and coverage for services provided.
- 1999-2008 National Government Services Medicare Part A and B appeals. Medical Review of provider, beneficiary appealed coverage determinations.
RN Case Manager/Discharge Planner
Horizon Home Health
05.1992 - 06.1999
- Managed complex cases involving multiple comorbidities, requiring close monitoring and coordination of various healthcare services.
- Collaborated closely with physicians to develop individualized treatment plans, supporting optimal patient outcomes.
- Educated patients and families on available community resources, facilitating access to necessary support services.
- Reduced hospital readmission rates through effective case management and patient education on self-care techniques.
- Coordinated care conferences with interdisciplinary team members, ensuring all perspectives were considered in the development of comprehensive treatment plans.
- Managed support services and fostered communication among social workers, therapists, hospital staff, and patients.
- Conducted thorough assessments of patients'' needs, enabling more accurate diagnoses and targeted interventions.
Education
Associate of Science - Nursing
Milwaukee Area Technical College
Milwaukee, WI05-1983
Skills
- Clinical judgment
- Discharge planning
- Quality improvement
- Licensed RN
- Complex Problem-solving
- EMR systems
- Proficient computer skills
Timeline
RN Medical Management II
Elevance/Anthem
06.1999 - 07.2023
RN Case Manager/Discharge Planner
Horizon Home Health
05.1992 - 06.1999
Associate of Science - Nursing
Milwaukee Area Technical College
Similar Profiles
Erika WilliamsErika Williams
Health and Dental Claims Adjuster at Elevance/AnthemHealth and Dental Claims Adjuster at Elevance/Anthem
Shayla TurnerShayla Turner
CALL CENTER CUSTOMER SERVICE AGENT at Elevance Health - Anthem FHPSCALL CENTER CUSTOMER SERVICE AGENT at Elevance Health - Anthem FHPS
Johnny GabiceJohnny Gabice
Customer Service Representative at Anthem Blue Cross Blue Shield/Elevance HealthCustomer Service Representative at Anthem Blue Cross Blue Shield/Elevance Health