Summary
Overview
Work History
Education
Skills
Core Competencies
Certification
Timeline
Generic

Kimberly Girten

Newark,DE

Summary

Seasoned Appeals Nurse Consultant, adept in medical records review and interprofessional collaboration. Demonstrated excellence in case management and healthcare standards, ensuring high-quality care and efficient appeal resolutions. Achieved significant improvements in appeal processing times, showcasing strong data analysis and autonomous work skills.

Overview

18
18
years of professional experience
1
1
Certification

Work History

Appeals Nurse Consultant

Aetna
Work At Home
07.2021 - 01.2025
  • Responsible for the review and resolution of coding appeals, utilization management appeals, and behavioral health appeals.
  • Collaborate with peers and colleagues to meet individual and department goals.
  • Follow department guidelines for decision-making, and conduct a thorough and extensive review of submitted documentation and all system information pertinent to the appeal request.
  • Conduct expedited member appeals with completion within 24 to 72 hours, for a duration of one week, every five weeks, and twice per year for weekends and holidays.
  • Special projects: Medicare provider appeals 11/2022 - current, and panel appeal hearings for behavioral health appeals 9/2023 - present.
  • Utilize multiple company systems, as needed, to obtain pertinent information in order to resolve appeals within established timeframes.
  • Apply and interpret appropriate policies and procedures, apply clinical criteria guidelines, appeal department, and regulatory standards while assessing appeal documentation and member needs to determine the appropriate administration of benefits.
  • Draft appeal resolution letter following department procedures and within NCQA guidelines.

Coding Appeals Nurse Consultant

Aetna
Work At Home
05.2018 - 07.2021
  • Responsible for review and evaluation of clinical information and documentation and application of appropriate clinical criteria and policies in line with regulatory and accreditation requirements for member and/or provider claims.
  • Reviewed of all documentation provided including medical records and system documentation to evaluate post-service claims for payment based on clinical policies, regulatory requirements and plan benefits.
  • Proficient at navigating through multiple payment system applications, including Microsoft Office(Word, Outlook, Excel, PowerPoint), and other web-based applications and outside vendors.
  • Ability to manage caseloads, meet turn-around times and production expectations, following department procedural guidelines and maintaining National Clinical Quality Audits (NCQA) standards.
  • Effective at analyzing complex issues, researching relevant information and using clinical judgement to resolve appeal.
  • Accurately applied review requirements to assure case was reviewed according to all company policies and procedures as well as state and federal laws and regulations.

Registered Nurse Health Coach

Aetna
Work At Home
03.2013 - 04.2018
  • Responsible for educating members on healthy lifestyle choices and provided resources for maintaining a healthy lifestyle.
  • Conducted regular check-ins with members to track progress and provide follow-up support.
  • Provided resources for maintaining a healthy lifestyle.
  • Collaborated with healthcare providers and inter-professionals to ensure comprehensive and coordinated care for our members.
  • Provided efficient and effective coaching strategies to encourage and promote lifestyle changes.
  • Utilized motivational interviewing techniques to encourage and empower members to facilitate change.
  • Maintained accurate and organized records of all coaching interactions and progress towards health goals.
  • Served as a positive and professional health liaison to improve the health and well-being of members.
  • Effectively communicated with members, providers, and other professionals in both oral and written format.

Home Health Nurse

Bayada
Delaware
01.2009 - 01.2010
  • Provided specialized nursing care to pediatrics, with various specialized needs, to maintain safe home life with comfort, independence, and dignity.
  • Utilized strong assessment skills and implemented care plans.
  • Direct care of pediatrics with tracheostomy and ventilator restricted to home care setting.
  • Committed to safe, high-quality home health care, delivered with compassion, excellence, and reliability.
  • Implemented care plans, and documented patient progress.
  • Determined and addresses individual home care needs by completing detailed assessments and reviewing documentation.
  • Provided exceptional care to high-acute patients needing complex care such as ventilator management, extensive wound care and rehabilitation.

Emergency Room Nurse

Christiana Care
Newark, DE
04.2007 - 04.2009
  • Provided care to patients all ages, treating patients with wide range of illnesses and/or injury in a Level 1 trauma center.
  • Teamed on trauma and emergency interventions involving serious head injuries, gunshot wounds, and thoracic trauma.
  • Delivered high level of quality care to diverse populations, triaging based on acuity and appropriate department admission.
  • Performed triage on incoming patients and determined severity of injuries and illnesses.
  • Promoted patient and family comfort during challenging recoveries to enhance healing and eliminate non-compliance problems.

Education

Bachelor's Degree - Behavioral Sciences

Wilmington University
Wilmington, DE
06.2012

Associate's Degree - Nursing

Cecil Community College
North East, MD
05.2007

Skills

  • Medical records review
  • Interprofessional collaboration
  • Strong data analysis
  • Reviewing standards of care
  • Proficient in medical terminology, healthcare laws, and standards
  • Skilled in case management
  • Collaborative and autonomous work skills

Core Competencies

  • Experience in review and resolution of coding appeals, utilization management appeals and behavioral health appeals.
  • Understands and protects confidentiality, abides by all HIPAA and associated patient confidentiality requirements.
  • Skilled at conducting thorough review of medical records with application of established guidelines.
  • Proficient in Microsoft Office, Word, Excell, Outlook and web-based applications.
  • Experience in Milliman Care Guidelines (MCG), Center for Medicare and Medicaid Regulations and Guidance, International Classification of Disease, Tenth Revision, Clinical Modification (ICD-10-CM), LOCUS (Level of Care Utilization System), CALOCUS (Child and Adolescent Level of Care Utilization System), and ASAM (American Society of Addiction Medicine) criteria.

Certification

Registered Nurse, L1-0035774, Expires 9/30/2025

Level of Care Utilization System for Psychiatric and Addictive Services (LOCUS) Basic Training

American Society of Addiction Medicine (ASAM)

Child and Adolescent Level of Care/Service Intensity Utilization System (CALOUS-CASII)

Timeline

Appeals Nurse Consultant

Aetna
07.2021 - 01.2025

Coding Appeals Nurse Consultant

Aetna
05.2018 - 07.2021

Registered Nurse Health Coach

Aetna
03.2013 - 04.2018

Home Health Nurse

Bayada
01.2009 - 01.2010

Emergency Room Nurse

Christiana Care
04.2007 - 04.2009

Bachelor's Degree - Behavioral Sciences

Wilmington University

Associate's Degree - Nursing

Cecil Community College

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Kimberly Girten