Linda Grimes

• Performance of auditing work in accordance with rigorous auditing standards and principles.
• Preparation of spreadsheets, reports and supporting documentation for audit findings.
• Review of medical records for discrepancies in documentation, coding, and appropriate care; referral of quality or process issues related to audits.
• Follow established auditing processes to meet internal and regulatory requirements.
• Consult with decision-makers to gather information and resolve audit-related issues.
• Compliance with federal, state and local requirements.
• Maintain professional knowledge by attending continuing education workshops, agency/state/federal training, and research into various medical services and associated policy/regulations.

• Managed day-to-day business operations, including but not limited to: payroll; scheduling (staff of 30); ordering supplies; doing inventory; customer service; event planning; troubleshooting issues with equipment, product quality, and vendors.
• Established, optimized and enforced business policies to maintain consistency and high-quality standards across industry operations.
• Created and monitored promotional approaches to increase sales and profit levels.
• Assessed supplier quality to maintain tight cost controls and maximize business operational performance.
• Aligned branding initiatives and sales strategies with client goals.
• Recruited, hired and trained initial personnel, working to establish key internal functions and outline scope of positions for new organization.
• Maximized efficiency by coaching and mentoring personnel on management principles, industry practices, company procedures and technology systems.
• Set, enforced and optimized internal policies to maintain responsiveness to demands.
• Trained and developed team members to build human capital.

Systems Integrity -

• Determined medical necessity of medical therapies, ambulance and outpatient hospital services, etc, as well as payment levels, according to Medicaid criteria
• Member of State Child Death Review Board, which reviewed every child death in state to determine gaps in state regulations/systems/processes, with goal of decreasing number of deaths
• Worked with physician consultants & coders on various payment/medical necessity issues.

Medical Audit Specialist-

• Audited various services (i.e., physician office visits, optometrists, school-based medical services, podiatric, chiropractic, Meals on Wheels, etc.), for medical necessity/utilization/reimbursement issues, in order to provide most appropriate and cost efficient services for members
• Helped developed new pre-pay audit subdivision for department, and was one of first people to perform that function.

Medical Audit Supervisor-

• Reviewed staff work hours for submission to payroll, performed evaluations, resolved issues with team members, reviewed leave requests, & audited cases to determine appropriateness/completeness for medical necessity/utilization/reimbursement issues. When field audit was necessary, facilitated smooth and efficient resolution of data collection, as well as issues which might arise during course of audit.

• Identified care needs of clients with work-related incidents (average case load of 50); coordinated responses based on physician advice, insurance limitations and procedural costs.
• Helped patients receive appropriate, high-quality care with reasonable results.
• Reduced care costs without sacrificing quality through effective service coordination and multidisciplinary collaboration.

• Counseled patients via telephone according to established guidelines and protocols, advising on provider-established plans of care.
• Obtained case history and gathered triage information to determine appropriate avenue for care.

• Oversaw laboratory and clinical environments to help students (7-10 students per group) advance knowledge and abilities.
• Assessed student knowledge levels and abilities with detailed assessments.
• Educated nursing students on successful methods for performing direct patient care techniques (IV start, personal care, vitals, etc).
• Taught Medical Terminology, Math for Meds, Med Surg Principles/pathophysiology (25-50 students per class). Evaluated curriculum with periodic updates to textbooks, syllabi, tests, quizzes, other evaluative techniques.
• Coached students on an individual basis to prepare them for NCLEX (required LPN licensure exam).

• Collaborated with other departments and medical staff to support provision of highest standard for total patient care.
• Promoted patient and family teaching to enhance patient understanding of needs and potentially accelerate recovery.
• Administered and maintained comfort, treatment, medication, intravenous infusion and health care to support patient needs.
• Submitted accurate documentation, reporting and in-depth nursing observation to support continuity of total patient care.
• Evaluated patients during admission, hospital stay and through discharge.
• Managed care from admission to discharge, including patient assessments, care planning, health educations and discharging support to provide comprehensive care.
• PRN Lead on Med-Surg floor, supervising RNs/CNAs to promote quality patient care.

• Communicated with parents regarding upcoming events and student progress.
• Established strong music foundation with students by incorporating basic music theory & history into weekly lessons.
• Engaged students in discussions on musical selection and composer histories.
• Developed lesson plans, selected course materials and prepared assignments.
• Coached/motivated students to enter & prepare for music contests, in order to increase self-confidence, & a sense of accomplishment

• Performed prior authorization review of surgical and/or hospital services requiring notification. Used Interqual, Milliman & Robertson, & other criteria to determine appropriateness of LOS (Length of Stay) & medical necessity for inpatient hospitalizations.
• Communicated with hospital case managers regarding current medical condition & discharge status of clients to provide appropriate, cost-effective care.

• Performed various nursing interventions such as wound dressing, vital sign monitoring and specimen collection.
• Gathered patient health data through interviews and observation, documenting data in electronic records.
• Directed patient care by initiating and following through with plan of care, continuing care and discharge instructions.
• Identified patient care requirements by establishing personal rapport with patients and families.
• Reported patients' status and delegated nurse assignments to achieve optimal outcomes.
• Administered medications via oral, IV and intramuscular injections and monitored responses.
• Assessed physical, psychological, physiologic and cognitive status of patients.
• Educated patients, families and caregivers on diagnosis and prognosis, treatment options, disease process and management and lifestyle options.
• Promoted patient independence by teaching self-care skills.
• Managed elements of patient care from admission to discharge or transfer to other units.
• Updated patient charts with data such as medications to keep records current and support accurate treatments.

• Monitored team performance, enforcing compliance with corporate claims processes and procedures.
• Evaluated interactions between associates and customers to assess personnel performance and customer satisfaction.
• Supervised approximately 10 staff members in providing excellent customer service to callers requiring assistance.
• Managed department call volume and coordinated department schedules to maximize coverage during peak hours.
• Helped employees with day-to-day work and complex problems by applying motivational and analytical strategies.
• Audited group insurance claims for accuracy prior to final adjudication.
• Developed pricing protocols for "By report" surgeries compared to established pricing for comparable surgeries.

• Answered incoming phone calls to articulate product value to prospective customers and support current policyholders.
• Documented customer contact to maintain record of customer interactions and elevate quality of service.
• Resolved issues with claims for members of Employer-sponsored health care plans.
• Processed claims based on individual employer health care plan benefits.
• Sent to Texas for 3 weeks to process outstanding claims for employees of Lockheed Corporation at Arlington office, to help staff catch up.

• Answered incoming phone calls to articulate product value to prospective customers and support current policyholders.
• Provided primary customer support to internal and external customers in fast-paced environment.
• Shared knowledge and expertise with co-workers to foster awareness and increase staff productivity.
• Responded to customer requests for products, services and company information.
• Processed/Reviewed medical claims for heart attack, cancer, & intensive care supplemental policies based on coverage available.