Kris Bozeman
Bremerton,WA
Summary
Organized, dedicated, and ambitious nurse with excellent attention to detail, and thirst for learning looking for a full-time remote position. I have contributed to the success of hospital owned clinics, private clinics, and a health plan. Offering training and supervision during my 26 years of nursing
Overview
26
26
years of professional experience
Work History
Lead Clinical Appeals Coordinator
Coordinated Care
05.2023 - Current
- Perform member appeal and provider claim dispute (provider appeals) audits
- Act as a departmental resource on member and provider appeals matters.
- Balance work load between 4 clinical appeals coordinators
- Identify and obtain additional information (medical records, WACs, policies, etc.) needed to make appropriate determination of appeals
- Prepare detailed written summary of case that did not meet medical necessity and send to medical director
- Ensure that appeals are resolved timely to meet regulatory timeframe
- Review clinical information utilizing InterQual, Clinical Policies, and State Regulations to determine medical necessity of services requested
- Communicate appeal outcome to member and provider
- Prepare response letters for member and provider clinical appeals and ensure letters meet state and NCQA requirements
- Document all findings in Trucare (enterprise care management platform)
- Adhere to desktop procedures, processes, and policies
- Stay current with NCQA and State regulations
- Coordinate Fair Hearings with Medical Directors, Pharmacy, Attorney, and outside agencies
- Work closely with medical directors, Utilization Management, Pharmacy, Claims, and other cross functional teams
Clinical Appeal Coordinator
Coordinated Care
08.2018 - 04.2023
- Identify and obtain additional information (medical records, WACs, policies, etc.) needed to make appropriate determination of appeal
- Prepare detailed written summary of case that did not meet medical necessity and send to medical director
- Ensure that appeals are resolved timely to meet regulatory timeframe
- Review clinical information utilizing InterQual and Clinical Policies to determine medical necessity of services requested.
- Communicate appeal outcome to member and provider
- Prepare response letters for member and provider clinical appeals and ensure letters meet state and NCQA requirements.
- Document all findings in Trucare.
- Adhere to desktop procedures, processes, and policies
- Stay current with NCQA and State regulations.
- Coordinate Fair Hearings with Medical Directors, Pharmacy, our Attorney, and outside agencies
- Perform member appeal and claim dispute audits
- Work closely with medical directors, Utilization Management, Pharmacy, Claims, and other cross functional teams
EPSDT Coordinator
Coordinated Care
04.2017 - 07.2018
- Conducted outreach to encourage members to access preventative care and assist with making appointments
- Collaborated with providers the importance of the EPSDT program, including well child checks and immunization schedules
- Maintained appropriate records, files, documentation
- Created month newsletter that centered on EPSDT elements directed at members and sent to providers
- Worked with Marketing department to plan outreach activities to increase HEDIS rates
- Attend EPSDT related DOH meetings as appropriate, such as Asthma Coalition and various Immunization programs
- Performed and completed accurate data entry of qualifying services and results into HEDIS electronic database software
Clinical Support Nurse
Northwest Medical Specialties
11.2016 - 03.2017
- Supported Medical Assistants and Providers with calls, orders, triaging, teaching, etc.
- Submitted prior authorization requests to patients medical or pharmacy benefit at their health plan
- Ordered specialty cancer medications through specialty pharmacies in coordination with patients insurance company
- Wrote appeal letters to insurance companies
- Triage patient needs, both in person and by phone to ensure timely access to appropriate health care services
- Provide medical education, advice and health care teaching to patients and their families in person and via telephone
Sr. Clinical Trainer / Employee Health Nurse
CHI Franciscan
05.2012 - 07.2016
- Delivered mandatory, regulatory, and educational/training programs during New Employee Orientation. On boarded Providers.
- Determined scheduling needs and scheduled trainers.
- Provided follow training and competency verification of skills, collaborated with management in order to meet their training needs.
- Provided feedback to supervisors and managers on how to meet training needs, report results through tracking of competencies, provide training on on EMR (EPIC).
- Associate Administrator on LEARN (HealthStream Learning Center) - track, report, and create education.
- Maintain and update database for regulatory requirements for clinical staff.
- Administer, read, and record TB skin testing.
- Serve as contact for employees reporting exposures and maintain logs, for blood borne pathogen exposure, manage follow up, and reporting to appropriate agencies.
- Onboard new employees, verify immunization status, perform FIT testing
- Collaborated with Health Department regarding reportable illnesses
Clinic Nurse
Franciscan Medical Group
03.2010 - 04.2012
- Evaluated patient history and current symptoms
- Triaged patients on phone and in the office
- Venipuncture
- Educated patients on upcoming procedures
- Performed breath hydrogen tests
- Prepare patient for physician
- Make follow up calls to patient with lab results
- Schedule follow up appointment
- Submit prior authorization requests via web portal, calling insurance companies
Clinic Supervisor
Taylor Regional Hospital
06.2003 - 02.2010
- Attended regular meetings with other clinic supervisors to discuss clinic operations and policies.
- Created and implemented policies to improve operational efficiency and patient care quality
- Managed daily operations of 28 nurses and medical assistants at 21 clinics
- Conducted frequent clinic walk-throughs to maintain safe work environment and
- Conducted monthly clinic walk-throughs to maintain compliance to JCAHO standards
- Delivered effective onboarding and training to new and existing employees
- Administered yearly medication examinations to nurses and monthly continuing education exams
- Perform yearly evaluation and give feedback to the nurses
- Coordinate community flu clinics
Clinic Nurse
Taylor Regional Hospital
02.1998 - 06.2003
- Worked in Pediatrics, Orthopedics, OB/GYN, Family Medicine, Internal Medicine, ENT, and General Surgery
- Prepare patients for healthcare provider visits including auditing charts in accordance with standards and policies
- Take vital signs as indicated, records patients’ histories, medications, and allergies in EMR
- Perform nursing procedures such as EKG, spirometry, ear lavage, injections, giving injections, dressing changes, urinary catheterizations, finger stick blood glucose testing, tympanograms and audiograms, casting and splinting
- Education of patients in a wide variety of subjects such as maternal/child health care, nutrition and life style issues, basic health care maintenance, and self-administration of medications
- Prepare appropriate instruments for examination or procedure, sterile and non-sterile
- Perform patient follow-up including notifying patients of laboratory results, scheduling referral appointments, maintaining charts and records, and responding to patient telephone calls
- Assist healthcare providers in procedures such as minor surgery, biopsy, colposcopy, treadmill, and stress testing
- Prior authorizations and appeals
Education
Certification - CPC (Certified Professional Coder)
AAPC (American Academy of Professional Coders
Remote11.2024
Diploma - Licensed Practical Nurse
Heart of Georgia Technical College
Dublin12.1997
Skills
- Time Management
- Critical Thinking
- Flexibility
- Teamwork
- Problem solving
- Leadership experience
- Self-motivation
- Computer skills
- Policy Interpretation
- Medical coding knowledge
Licensing
Multi-state (Compact License)
License Number: LP601381132
Expiration Date: 4/4/2025
Timeline
Lead Clinical Appeals Coordinator
Coordinated Care
05.2023 - Current
Clinical Appeal Coordinator
Coordinated Care
08.2018 - 04.2023
EPSDT Coordinator
Coordinated Care
04.2017 - 07.2018
Clinical Support Nurse
Northwest Medical Specialties
11.2016 - 03.2017
Sr. Clinical Trainer / Employee Health Nurse
CHI Franciscan
05.2012 - 07.2016
Clinic Nurse
Franciscan Medical Group
03.2010 - 04.2012
Clinic Supervisor
Taylor Regional Hospital
06.2003 - 02.2010
Clinic Nurse
Taylor Regional Hospital
02.1998 - 06.2003
Certification - CPC (Certified Professional Coder)
AAPC (American Academy of Professional Coders
Diploma - Licensed Practical Nurse
Heart of Georgia Technical College
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