Khanthaly Chanthasene

See above summary

• Developed, defined, and implemented roles and responsibilities for 22 clinical reviewers and senior clinical reviewers
• Ensured staff compliance with the SOW (statement of work) governmental contract between Medicare and SMRC, and Noridian and corporate policies as well as SMRC SMRC procedures
• Developed and assisted with the creation of policies and procedures for the SMRC clinical reviewer position.
• Created powerpoint trainings and conducting annual training sessions to meet annual company requirements (BIA/BCCP training)
• Approved weekly staff time keeping as well as paid time off, short-term leave, and long-term leave.
• Contributed to the efficiency of provider responses to medical record requests by effectively communicating with operational staff daily/weekly as well as identifying process improvements
• Developed and monitored staff personal and career development by holding weekly one-on-one discussions on work load, progression of goals, and plans/supervisory feedback for improvement, as well as performed yearly evaluations
• Directly communicated with CMS by email, webinar and conferences on the status of regarding CMS assigned SMRC Program Integrity (PI)and Healthcare Fraud Prevention Program (HFPP) projects. Advised CMS on recommendations and referrals for providers of subject through CMS email requests
• Directed all operational needs for CMS projects, including ensuring receipt of HH, Part B, DME, and Hospice data from CMS, finalization of data in collaboration with statisticians, operational staff, contract program director and medical review manager, creation of each project specific Access Database (limited electronics program for medical review decisions), assigning appropriate staffing, along with project and benefit specific training
• Prepared monthly project summary reports for CMS (including each project background and investigational development of CMS projects, development of project trainings, applicable Medicare guidelines, summary of medical review findings, trends and observations
• Performed medical reviews of Part B, DME, Hospice, and some Home Health claims as needed, while also assisting with quality assurance
• Acted as a subject matter expert in fraud review of Part A, Part B and DME data analysis
• Challenged and motivated staff to develop innovative strategies for improvement of SMRC

• Prioritized and completed assigned medical review assignments as well as assigned quality assurance reviews for the ZPICs and UPICS, while meeting CMS metrics for each case
• Performed medical review of prepay and postpay claims (including Part A and B of A reviews, Part B, and Hospice)
• Applied knowledge and understanding of CPT, HCPCS, ICD, RUG codes, DRG, Revenue codes, LCDs, NCDs, FISS, HIMR, and Federal and State Regulations to medical review decisions (including SSA and 42 Code of Federal Regulations, CMS Internet Online Manuals and CMS NCCI Manuals, etc)
• Performed quality assurance reviews for all Part A and B medical reviews (prepay and postpay) for multiple states in the UPIC MW jurisdiction (including the accuracy of clinical decisions, coding/recoding, evidence in medical records, analyzing beneficiary claims history for support, and application of the appropriate Medicare rules and regulations)
• Assisted in the development and implementation of the QA process between the QA department and medical review departments across multiple UPICS and ZPICS
• Created, developed, and conducted role specific trainings for new medical reviewers on UPICMW and ZPICs
• Discussed and intervened in unresolved clinical questions between the QA nurse and the medical reviewer through the formal QA appeals process
• Consulted with medical review management as well as Quality Assurance management/nurses to educate on QA standards
• Monitored QA procedures for adherence by medical review department as well as QA department, notifying both departments of non-compliance issues, including quality and timeliness of medical reviews delivered by the ZPICs and UPIC Midwest
• Researched individual cases and supported medical reviewers, statisticians and PI (Program Integrity) Analysts in the direction of review decisions, case development, quality of care, beneficiary harm, and trends and observations indicative of fraud, waste, or abuse
• Researched upcoming changes to Medicare rules and regulations, providing updates/trainings to the medical review department
• Assisted the Quality Assurance Manager with any previous QA reporting responsibilities to senior management
• Closely communicated daily with UPIC/ZPIC Medical review managers, medical reviewers medical review technical clerks, and QA department on the status and timeliness of all cases in QA workload

• See above summary for role as Quality Assurance Specialist IV for Zone 2, Zone 5 and UPIC Midwest

• Performed medical record review of Part A and Part B claims (post-pay and pre-pay) for compliance to Medicare rules and regulations
• Researched, interpreted, and applied the appropriate Medicare rules and regulations (indications/coding and billing) codes to each assigned review
• Synthesized final medical review decisions/data into comprehensive written summary for the PI Analyst
• Educated the PI Analyst and provider in correcting compliance and technical errors in billing and medical documentation
• Asssisted the PI Analyst in the development of a case, including research of applicable Medicare guidelines, clinical input, analyzation of data, and development of the medical record request letter.

• See above summary

• Assigned and monitored daily staffing as well as serving as on-call nurse 24 hours/ day 7 days per week
• Temporarily acted as manager of a 100 bed assisted living community
• Assisted the Executive Director on operational cost-efficient decisions on housekeeping, medical supplies, all staff adherence with company policies and procedures and Ohio regulations, and departmental procedures.
• Collaborated with the Executive Director and Community Relations Director (Marketer) in increasing census of the community with overall goal of increasing staffing

• Managed a 21 bed secured unit specializing in implementing a memory based program for those affected by Alzheimer’s and other types of Dementia
• Clinical expert, leader, and educator of the disease process of Dementia along with a team of other RNs, LPNs, Home Care and Hospice, Vendors, Therapists, and Social Workers in directing the care and needs of each Dementia resident
• Personally gave prospective residents and families tours of memory care unit, answering questions about services and facility.
• Performed initial, 30 day, and semi-annual evaluations of 98 residents, including the creation and development of an on-going plan of care for each Dementia resident
• Conducted monthly ongoing seminars for all staff in order to be compliant with state regulations
• Actively developed and implemented the program “Join Their Journey” dedicated to the life story of an individual affected by Dementia/ Alzheimer’s
• Provided emotional and educational support to families affected by the council meetings, and family gatherings
• Coordinated care plan meetings with the families and disciplinary team in problem solving and providing education and emotional support to families
• Responded to resident to resident altercations in calm approach, role-modeled to staff and families, and providing education on how to approach situation.
• Responsible for the hiring and day to day staffing of nurses, concierge, and resident assistants, dealing with all call-offs, staff injuries, counseling, and coaching
• Coordinated orientation class for all staff members, conducted monthly all staff meetings, ongoing yearly educational requirements, and first aid certification
• Trained, supervised, and coordinated all members of the nursing department in meeting excellent service standards
• Responsible for yearly resident and staff TB (Tuberculosis) injections, resident annual history and physical assessments.

• Performed nursing care (tube feeding, assessments, turning, communication with physicians and other healthcare members, etc) as well as provide teaching to patients with a skilled need and patients on the long term care area of the unit
• Communicated with the unit manager on a daily basis in ensuring the flow of the unit (ordered supplies, communicated nursing and patient concerns, discussions with physicians and consequently nursing staff)
• Monitored and managed various treatment and care interventions.
• Updated physicians on patient test results and assisted in developing care plans.
• Advocated for patients by supporting and respecting basic rights, values and beliefs.
• Trained and mentored new RNs on best practices, hospital policies and standards of care.
• Oversaw patient admission and discharge processes to coordinate related paperwork.
• Responsible for scheduling nurses and certified nursing assistant schedules, filling in nurse’s shift as needed, and rotating to other units as well to fill nursing shifts.

• Provided nursing care (tube feeding, suctioning, assessments, turning, communication with physicians and other healthcare members, etc) to critically ill patients in the ICU and CCU areas while under the mentorship of another experienced nurse on the unit and while receiving focused education on cardiac care

• Performed physical, emotional, neurological, and functional health assessments on patients recently hospitalized or difficulty caring for oneself at home
• Provided education on various health problems (Diabetes, dressing changes, medications, medication management, lifestyle changes)
• Established the home health plan of care to ensure that nursing staff and home health aides meet the needs of each home health patient
• Responsible for supervising and educating nursing staff and home health aides in making sure patient’s needs are met.