Kathy Searle
Columbia,SC
Summary
Dynamic Clinical Nurse Reviewer with expertise in medical record review and a strong commitment to patient safety. Proven track record at Acentra Health in optimizing resource allocation and enhancing team performance through quality improvement initiatives. Excellent communication and problem-solving skills, ensuring compliance with healthcare regulations and driving continuous process enhancements.
Overview
14
14
years of professional experience
1
1
Certification
Work History
Clinical Nurse Reviewer
Acentra Health
02.2023 - Current
- Contacted providers, state agency offices and applicants to obtain information and records needed to conduct comprehensive clinical review of case and final determination.
- Participated in quality assurance initiatives by conducting peer reviews and providing constructive feedback to enhance overall team performance.
- Optimized resource allocation by identifying areas of overutilization or underutilization within the healthcare system.
- Demonstrated expert knowledge of medical terminology, pharmacology, anatomy, and physiology while conducting accurate clinical assessments.
- Reviewed and documented relevant information into data system applications.
- Exhibited strong analytical skills when interpreting complex medical records to evaluate patient care outcomes against established benchmarks.
- Managed caseload efficiently while maintaining strict confidentiality of sensitive information per HIPAA regulations.
Quality Assurance Specialist
Dane Street, LLC
02.2021 - 01.2023
- Provided regular updates to team leadership on quality metrics by communicating consistency problems or production deficiencies.
- Ensured product compliance with industry regulations by staying up-to-date on relevant standards and guidelines, implementing necessary changes to maintain conformance.
- Enhanced customer satisfaction by addressing reported issues promptly and providing effective solutions.
- Optimized workflow efficiency by introducing automation tools into the QA process where appropriate.
- Utilized root cause analysis techniques to identify underlying issues contributing to product defects or customer complaints.
- Mentored junior QA specialists, fostering a culture of continuous learning and professional growth.
- Educated employees on specific QA standards and confirmed maintenance of standards.
Appeals Analyst
Cigna
01.2018 - 01.2021
- Managed a high volume of cases, prioritizing tasks effectively and meeting strict deadlines for appeals resolutions.
- Improved the efficiency of the appeals process by reviewing and analyzing claim denials and discrepancies.
- Investigated fraudulent activities and recommended corrective actions, safeguarding company resources and maintaining the integrity of the appeals process.
- Contributed valuable insights during policy development meetings, integrating an expert understanding of industry regulations into organizational policy changes.
- Conducted thorough research on industry trends, staying informed on best practices for effective appeals management.
- Utilized guidelines and review tools to conduct extensive research and analyze grievance and appeal issues.
- Analyzed and rendered determinations on assigned non-complex grievance and appeal issues.
- Collaborated with interdisciplinary teams to ensure accurate claims adjudication, reducing errors and inconsistencies in the review process.
- Facilitated cross-departmental collaboration by working closely with clinical staff and legal personnel during case reviews.
Revenue Integrity Nurse Analyst
HCA/Parallon Business Solutions
12.2010 - 01.2018
- Evaluated the effectiveness of revenue integrity initiatives through regular reporting and analysis, identifying areas for improvement and driving continuous process enhancements.
- Managed data analysis for accurate charge capture and improved overall financial health of the organization.
- Conducted root cause analyses for identified issues, recommending appropriate actions for resolution and prevention of future occurrences.
- Monitored accounts receivable performance metrics regularly, taking action when necessary to improve collection rates or resolve outstanding issues promptly.
Education
No Degree - Communications
Brigham Young University
Provo, UTAssociate of Science - Practical Nursing
SLCC
Salt Lake City06-1989
Skills
- Nursing documentation
- Medical record review
- Patient safety
- Clinical judgment
- HIPAA
- Quality improvement
- Healthcare regulations
- Policy compliance
- Continuing education
- Utilization review
- Teamwork
- Problem-solving
- Medication and IV administration
- Problem-solving abilities
- Excellent communication
Certification
- Licensed [Job Title] - [Timeframe]
Timeline
Clinical Nurse Reviewer
Acentra Health
02.2023 - Current
Quality Assurance Specialist
Dane Street, LLC
02.2021 - 01.2023
Appeals Analyst
Cigna
01.2018 - 01.2021
Revenue Integrity Nurse Analyst
HCA/Parallon Business Solutions
12.2010 - 01.2018
No Degree - Communications
Brigham Young University
Associate of Science - Practical Nursing
SLCC
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