Team-oriented professional prepared to take on leadership responsibilities with focus on driving results and fostering collaboration. Proven success in managing teams, overseeing project execution, and adapting to dynamic work environments. Known for reliability, flexibility, and strong organizational skills, ensuring seamless team operations and achievement of goals.
Overview
23
23
years of professional experience
1
1
Certification
Work History
Team Lead/Nurse Auditor / Revenue Recovery Consultant II
JZANUS CONSULTING INC
06.2021 - Current
Performs detailed reviews for Medicare and Medicaid bills in conjunction with the patient’s medical record ensuring that every billable item, procedure, pharmaceutical and medical supply was captured on the revised itemized bill
Creates a detailed report with correct and additional missing items off the itemized bill
Assesses denials of chargeable items received from IPRO, Empire, Optum, Equian, and Medreview and opens an investigation in the medical record to find supporting clinical information to formulate and coordinate a formal appeal
Appeals denied length of stay by finding the acuity of the patient’s illness and supporting clinical- criteria based documentation in the medical record
Prioritizes work in a timely manner to ensure responses are submitted in the required timeframes
Identifies, reviews, and monitors findings on denials and cost outliers to avoid future loss of revenue to our clients
Trains and provides education to colleagues and support staff
Clinical Denial Appeals Specialist
NORTHWELL HEALTHCARE SYSTEM
11.2017 - 06.2021
Company Overview: FINANCE REVENUE CYCLE
Reviewed coordinates utilize reviews concurrently and retrospectively to prevent denials from managed care and third-party reviewers for inpatient admissions.
Sorted, reviewed, and evaluated cases denied by Third party payers and determined follow through for first level appeals within contractual or appropriate timeframes.
Determined whether all relevant clinical information has been submitted to the insurance carrier
Identified if cases warrant review by a physician advisor
Wrote first and second level insurance appeal letters
Maintained data tracking systems and provides reports to patient accounts, director of denial prevention, and physician advisors
Participated in departmental continuous quality improvement activities and committees
Promoted staff development and education
Ensured compliance with HIPAA regulations to include confidentiality
SRG NURSE-Volunteered to be deployed to the Special Response Group
NORTHWELL HEALTHCARE SYSTEM
04.2020 - 09.2020
Company Overview: SPECIAL RESPONSE GROUP COVID
Employed combination of communication skills and related experience to provide for adaptation in an ever-changing environment
Utilized clinical experience to guide colleagues and patients to the appropriate level of care
Established a department with limited resources to aid in the pandemic of the coronavirus in the New York region
Nurse Case Manager
NORTHWELL HEALTHCARE SYSTEM
05.2014 - 11.2017
Company Overview: QUALITY MANGEMENT/CARE MANAGEMENT
Ensured managed care reviews are up to date and accurately reflect patient's acute needs and clinical progress assesses each patient physically, psychosocially, and financially served as a patient liaison-assessing, planning, implementing, and evaluating patient in collaboration with the health care team
Worked with acute care and traumatic brain injury patients
Communicated with administration and insurance companies regarding utilization issues and discharge plan
Identified discharge needs and facilitates plan to ensure the best outcome for patient
Case Management, PRI, and Screen Certified
Interacted with physicians, nursing staff, case management and medical coding staff to facilitate modifications to clinical documentation
Provided educational programs as required
Clinical Documentation Specialist
NORTH SHORE LONG ISLAND JEWISH HEALTHCARE SYSTEM
09.2008 - 05.2014
Company Overview: Worked within numerous hospitals throughout the healthcare system
Improved quality and completeness of clinical documentation in the medical record
Interacted with physicians, nursing staff, case management and medical coding staff to facilitate modifications to clinical documentation
Provided educational programs as required
Served as a resource to Physicians, Case Managers and other key professional staff regarding DRG/coding clarification
Compiled and provided timely statistical reports
Worked with medical records, finance, and physician groups to develop systems to facilitate complete documentation for data reporting
Registered Nurse Cardiology
NORTH SHORE LONG ISLAND JEWISH HEALTHCARE SYSTEM
05.2002 - 09.2008
Assessed patients’ physiological and psychosocial health status
Explained policies and procedures to patients and significant others
Answered questions correctly and courteously
Determined mobility, sensory deficits, prostheses use and skin condition and adjusted plan of care as appropriate
Determined coping mechanisms, knowledge level and ability to comprehend
Collaborated with health care team members in carrying out treatment regimen
Identified cultural and ethnic requirements to reduce anxiety and ensure patient satisfaction
Participated in planning for discharge and coordinated referrals as appropriate
Provided emotional support to patients and significant others
Acted as preceptor and charge nurse
Utilize leadership skills/clinical judgment in coordinating patient care and directing /delegating activities of the patient care unit team
Education
Bachelor of Science - Nursing
Molloy College
Rockville Centre, NY
01.1999
Bachelor of Science - Business Administration
Long Island University C.W. Post
05-1989
Skills
Attention to detail
Customer focus
Coaching and mentoring
Performance monitoring
Performance improvement
Quality control
Production monitoring
Employee evaluation
Relationship building
Talent acquisition
Deadline management
Employee training
Task delegation
Strategic planning
Workflow management
Certification
Registered Professional Nurse in the State of New York 511725
PRI certified
Timeline
Team Lead/Nurse Auditor / Revenue Recovery Consultant II
JZANUS CONSULTING INC
06.2021 - Current
SRG NURSE-Volunteered to be deployed to the Special Response Group
Adult Gerontology Nurse Practitioner/Palliative Care Nurse Practitioner at Maimonides Medical CenterAdult Gerontology Nurse Practitioner/Palliative Care Nurse Practitioner at Maimonides Medical Center