Laura Chiaravalloti
Lakewood
Summary
Dynamic and dedicated nursing professional with a proven track record of clinical expertise, leadership, and technical proficiency. Proficient in reviewing medical records and navigating Medicare/Medicaid regulations, with a strong ability to interpret contracts and official documents accurately. Committed to fostering team success through a quality-driven approach and exceptional interpersonal skills. Eager to contribute to a collaborative environment prioritizing patient care and operational excellence.
Overview
25
25
years of professional experience
1
1
Certification
Work History
Clinical Claim Review Nurse
United Healthcare
10.2003 - Current
- Determined medical necessity and cost-effectiveness of services through utilization review processes.
- Applied medical criteria and clinical judgement to researched cases to evaluate and establish determinations.
- Remained up-to-date on various benefit plans, medical policies and state-specific clinical guidelines or criteria.
- Referred cases to secondary review for failure to meet MCG and Interqual criteria.
- Reviewed patient admissions to determine medical necessity as directed by MCG and Interqual criteria.
- Kept detailed documentation on all utilization reviews by using ICUE/HSR.
- Managed appeal processes pertaining to denials and potential denials as outlined by insurance carriers.
- Collaborated with Manager's in group meetings to identify issues and find cost-effective solutions.
- Conducted complex research, review and analysis of medical records, treatment plans and claim information.
- Maintained strict patient data procedures to comply with HIPAA laws and prevent information breaches.
- Maintained updated knowledge of coding requirements, which included continuing education and certification renewal.
- Maintained current working knowledge of CPT and ICD-10 coding principles, government regulation, protocols and third-party billing requirements.
- Coordinated with manager's to provide one-on-one support for team members as the Subject Matter Expert .
- Assessed performance of fellow nurses and motivated necessary change to meet department benchmarks as the team auditor.
Concurrent Review Nurse
Benefit Planners
10.2002 - 10.2003
- Coordinated with healthcare team to establish, enact and evaluate patient care plans.
- Utilized computerized Resource and Patient Management System (RPMS) and Electronic Health Record (EHR) system.
- Participated in continuing education programs and workshops to enhance training and nursing knowledge.
- Gathered community resources and coordinated referrals to obtain services.
- Documented services and collected required data for evaluation.
- Maintained strict patient data procedures to comply with HIPAA laws and prevent information breaches.
Quality Assurance Nurse
Americare Home Health Services
06.2001 - 10.2002
- Consulted with management and personnel to educate on QA standards.
- Monitored QA procedures for adherence by employees, notifying personnel of non-compliance issues.
- Collaborated with management to discuss effective plans for resolving major quality problems.
- Contributed to business growth by confirming customer satisfaction with service and quality.
- Enhanced customer satisfaction ratings by building client rapport and timely resolving crises and issues.
- Supervised onboarding and training of new personnel to maximize capacities of quality assurance team.
- Met with development team to interpret data and analysis provided in monthly reports.
Education
Associate of Applied Science - Registered Nurse
Lower Columbia College
Longview, WA08-2024
LPN Certificate - Nursing
St. Philip's College
San Antonio, TX12.1998
Skills
- Clinical utilization review
- Employee training and mentoring
- Experienced with MS Office applications
- Data analysis proficiency
- Skilled in Microsoft word/excel
- Data security practices
- Insurance industry experience
- Medicaid regulations expertise
- Knowledge of insurance terms
- Regulatory compliance understanding
- Medical terminology
- Documentation skills
- Friendly, positive attitude
- Working collaboratively
- Team building
- Experience in leadership
- Content management expertise
- Computer skills
- Communication
- Problem-solving skills
- Proficient in managing multiple tasks
- Training & Development
- Relationship building
- Clinical documentation
- Patient assessment
- Patient education
- Clinical judgment
- Compassionate care
- Patient management
Certification
- Certified Professional Coder (CPC)
Timeline
Clinical Claim Review Nurse
United Healthcare
10.2003 - Current
Concurrent Review Nurse
Benefit Planners
10.2002 - 10.2003
Quality Assurance Nurse
Americare Home Health Services
06.2001 - 10.2002
LPN Certificate - Nursing
St. Philip's College
Associate of Applied Science - Registered Nurse
Lower Columbia College