Lisa Articolo
Schenectady,NY
Summary
Experienced Clinical Appeals Specialist successful at managing high caseloads in fast-paced environments. Organized, driven and adaptable with excellent planning and problem-solving abilities. Offering 8 years of appeals experience and willingness to take on any challenge.
Overview
18
18
years of professional experience
Work History
Appeals and Grievances Clinical Specialist
Healthfirst
04.2021 - Current
- Managed high-stress situations with professionalism, ensuring that appeals were handled promptly and accurately even under tight deadlines or heavy caseloads.
- Collaborated with team members to resolve complex cases, leveraging collective expertise and knowledge for optimal outcomes.
- Increased departmental productivity by prioritizing tasks effectively and maintaining strong attention to detail in all aspects of the appeal process.
- Maintained strong knowledge of MCG Guidelines to ensure accuracy of reviews.
Utilization Review Manager
Fidelis Care New York
06.2019 - 04.2021
- Oversaw internal audits to ensure compliance with regulatory bodies such as CMS within utilization review department.
- Established key performance indicators for department, monitoring progress toward goals and driving continuous improvement.
- Developed, implemented and maintained compliance of policies and procedures regarding utilization management functions.
- Developed comprehensive staff training programs to enhance employees'' understanding of utilization review principles and practices.
Utilization Management Nurse
Fidelis Care New York
01.2019 - 06.2019
- Accurately reviewed clinical documentation to assess medical necessity of requested services.
- Ensured compliance with regulatory guidelines by staying current on industry standards and participating in ongoing education opportunities.
- Promoted positive work environment by mentoring new nurses and serving as resource for clinical questions and concerns.
- Communicated with providers to gather additional clinical information not included in initial submission to make accurate determinations.
Case Manager
MVP
10.2018 - 01.2019
- Coordinated care to help address members health care needs through home visits and phone calls after hospital discharge.
- Assisted members in transitioning from acute care setting to home to reduce risk of re-hospitalization.
- Worked with members to implement discharge instructions to include medication reconciliation and coordination of follow up appointments.
- Provided education to assist in self-health governance and home management of disease process.
- Conducted thorough assessments of members situations, identifying issues, goals, and necessary interventions.
Utilization Management Nurse
Fidelis Care New York
05.2017 - 10.2018
- Accurately reviewed clinical documentation to assess medical necessity of requested services.
- Ensured compliance with regulatory guidelines by staying current on industry standards and participating in ongoing education opportunities.
- Promoted positive work environment by mentoring new nurses and serving as resource for clinical questions and concerns.
- Communicated with providers to gather additional clinical information not included in initial submission to make accurate determinations.
Community Care/Utilization Review Nurse
Department of Veterans Affairs
06.2016 - 05.2017
- Applied clinical knowledge to aid in coordination of numerous health care services for Veterans both within and outside facility.
- Assessed medical documentation to establish medical necessity of proposed treatment plans from providers.
- Offered professional guidance, supervision, and leadership to staff.
- Educated colleagues on clinical care needed for medical diagnoses and documentation requirements to establish medical necessity.
- Collaborated with case managers to discuss inpatient status and coordinate discharge plans.
- Investigated complaints (Congressional) Veterans submitted to their Congressman, provided rebuttals with supporting documentation to Director, Associate Director and Chief of Nursing.
Case Manager
Department of Veterans Affairs
04.2008 - 06.2016
- Lead role in creating and successfully implementing transitional care program based upon evidenced based practices.
- Served as transitional coach following Veterans from acute care setting to home environment.
- Served as resource to colleagues to help improve documentation in Computerized Patient Record System (CPRS) based upon nursing standards of care, Joint Commission, and facility regulations.
- Evaluated and accurately documented patients' responses to interventions and modified their plan of care as necessary to achieve patient goals.
- Worked collaboratively as member of a multi-disciplinary team to identify, analyze, and resolve patient care problems to improve outcomes.
- Developed individualized care plans specific to patients physical, mental, and social needs based on nursing assessment and standards of care.
- Managed caseload of 25-35 clinically complex Veterans overseeing their medical, social, and psychological needs.
Case Manager
Visiting Nurse Service of Northeast New York
01.2006 - 04.2012
- Provided skilled nursing care to diverse patient population including adult, geriatric, and psychiatric patients.
- Responsible for all follow-up patient care including communication with providers and coordinating community resources.
- Supervised care provided by ancillary staff.
- Member of Wound Care Specialist Team and acted as resource to staff for wound care assessments, and selection of appropriate wound care treatments.
- Preceptor for newly hired nurses and acted as mentor to staff to improve nursing retention.
Education
B.S. Nursing -
Excelsior College
Albany, NY05.2012
Diploma Registered Nurse -
Albany Memorial School of Nursing
Albany, NY12.2005
Diploma Licensed Practical Nurse -
Capital Region Career and Technical School
Albany, NY06.1997
Associate of Applied Science Paralegal -
State University of New York at Schenectady County
Schenectady, NY05.1994
Skills
- Clinical expertise
- EMR Documentation
- Quality Assurance
- Critical Thinking
- Clinical Recommendations
- Appeals Process Proficiency
- Healthcare Regulations Expertise
- Skilled in MCG
- Medical Records Review
- Organizational abilities
- Strong analytical skills
Credentials And Licenses
- Registered Nurse, 570869-1, New York
- Peer Review Instrument Certification
Timeline
Appeals and Grievances Clinical Specialist
Healthfirst
04.2021 - Current
Utilization Review Manager
Fidelis Care New York
06.2019 - 04.2021
Utilization Management Nurse
Fidelis Care New York
01.2019 - 06.2019
Case Manager
MVP
10.2018 - 01.2019
Utilization Management Nurse
Fidelis Care New York
05.2017 - 10.2018
Community Care/Utilization Review Nurse
Department of Veterans Affairs
06.2016 - 05.2017
Case Manager
Department of Veterans Affairs
04.2008 - 06.2016
Case Manager
Visiting Nurse Service of Northeast New York
01.2006 - 04.2012
B.S. Nursing -
Excelsior College
Diploma Registered Nurse -
Albany Memorial School of Nursing
Diploma Licensed Practical Nurse -
Capital Region Career and Technical School
Associate of Applied Science Paralegal -
State University of New York at Schenectady County