Karen Tanguay
Summary
Experienced RN Quality Auditor/Appeals Nurse/Medical Reviewer with a strong background in quality control processes, documentation management, and internal auditing. Proven ability to review and assess medical claims and appeals claims for accuracy, compliance, and medical necessity while tracking regulatory changes. Detail-oriented quality control specialist with methodical approach to auditing processes and ensuring compliance with industry standards. Demonstrates expertise in identifying discrepancies, implementing corrective actions, and maintaining meticulous documentation to uphold product quality and safety. Reliable worker with excellent communication, time management, and computer skills. Known for reliability and adaptability, with focus on ensuring product and process quality.
Overview
14
14
years of professional experience
1
1
Certification
Work History
QUALITY AUDITOR/MEDICAL REVIEW NURSE
Elevance Health/National Government Services
05.2011 - 07.2025
- I began working for Elevance Health/NGS as a Medical Reviewer. I reviewed Medicare Medical Part A claims to determine payment and coding eligibility as instructed by CMS guidelines. I started as a Quality Auditor in 2021. In this role, I audited Appeals claims and Medical Review claims. My role as a Quality Auditor included auditing all claims for accuracy, correct coding for services provided and billed, grammar on Appeals claims and medical necessity.
- Maintained accurate records of all audits, and other activities related to product quality.
- Created comprehensive documentation of audit results, including findings, recommendations, and corrective actions taken.
- Assisted management with identifying key areas in need of improvement to maximize efficiency.
- Analyzed audit findings for accuracy and completeness in accordance with regulatory requirements and company policies and procedures.
- Additionally, I tracked changes in applicable regulations affecting these claims.
- I documented all audit results, including findings, recommendations, and corrective actions taken. As a Medical Review nurse and Quality Auditor, I provided education to staff and providers on coding and adherence to rules and regulations.
RN SUPERVISOR
Maine Veterans Home
08.2019 - 04.2022
- Demonstrated ability to effectively manage and supervise a team of nurses and other healthcare professionals.
- Performed regular performance evaluations for direct reports providing constructive feedback as needed.
- Cultivated positive relationships with residents, families and staff.
- Provided exemplary leadership, guidance, and support to nursing staff in accordance with established policies and procedures.
RN CHARGE NURSE
Augusta Health and Rehabilitation Center
10.2018 - 04.2019
- Reported symptoms, condition changes and vital signs to primary care doctors, patients, and families.
- Kept accurate records and charts related to medications and treatments according to policies, procedures, and physician orders.
- Performed ongoing patient assessments, notifying supervising clinician of abnormal findings.
Education
Associates Degree - Nursing
Abraham Baldwin Agricultural College
Tifton, GASkills
- Internal auditing
- Organizational skills
- Corrective action planning
- Excellent communication
- Standards compliance
- ISO standards
- Training and coaching
- Critical thinking
- Compliance requirements
- Quality control processes
Certification
RN42031
Timeline
RN SUPERVISOR
Maine Veterans Home
08.2019 - 04.2022
RN CHARGE NURSE
Augusta Health and Rehabilitation Center
10.2018 - 04.2019
QUALITY AUDITOR/MEDICAL REVIEW NURSE
Elevance Health/National Government Services
05.2011 - 07.2025
Associates Degree - Nursing
Abraham Baldwin Agricultural College
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