Summary
Overview
Work History
Education
Skills
Certification
Personal Information
Assessments
Timeline
Generic

Lisa Milton

North Richland Hills,USA

Summary

Experienced healthcare professional with a strong background in managing complex patient cases and optimizing care coordination at Wellmed/USMD. Expertise in HEDIS data analysis and patient medical records management complements proficiency in ICD-10 and CPT coding accuracy. Demonstrated success in enhancing healthcare delivery through rigorous quality management practices and exceptional communication skills, resulting in improved patient outcomes. Career aspirations include further advancing healthcare quality initiatives and leadership opportunities.

Overview

13
13
years of professional experience
1
1
Certification

Work History

Healthcare Coordinator, LVN

Wellmed/USMD
Fort Worth, Texas
09.2023 - Current
  • Works with the PCP and clinic staff to identify patients with high-risk diagnoses such as CHF, IHD, COPD/asthma and diabetes and ensures clinical guidelines are being followed
  • Contacts and performs initial interviews with patients who are in need of health coaching programs
  • Conducts Chronic Care Model visits and reviews the patient’s informal and formal support systems, focusing on what patients want to improve and educating them about their chronic disease
  • Provide necessary coaching to reduce or eliminate behaviors that are considered high-risk
  • Identify the required goals that each patient must fulfill and advise feasible options for achieving the goal
  • Ensure that patients are made aware of health issues, concerns, and the way in which one can combat them
  • Must raise awareness about the different available exercises, weight loss programs and other dietary requirements necessary for a healthy lifestyle
  • Utilizes appropriate motivational interviewing techniques necessary for coaching and assisting the patient to complete a self-management goal/action plan
  • Must be able to provide a chart of habits and lifestyle changes that are imperative for the improvement of the concerned patient’s health
  • Enter timely and accurate data into the electronic medical record to communicate patient needs and to ensure complete documentation of patient visits and phone calls
  • Tracks self-management goal outcomes and documents in electronic medical record
  • Maintains current knowledge regarding CHF, IHD, COPD/asthma and diabetes as well as related treatments and complex medications
  • Assists, initiates referrals, and coordinates transitions of car regarding hospitalization follow-up, palliative care, hospice, etc
  • Establishes a trusting relationship with identified patients, caregivers, clinic staff members and physicians
  • Attends educational offerings to keep abreast of change and complies with licensing requirements, ensures all patient educational materials are up-to-date, and maintains knowledge of specialty and ancillary provider contract contents, to include exclusions and contract terms
  • Conducts clinic one-on-one visits with Disease Management Chronic Care Program participants, utilizing the Chronic
  • Care Model, to assess patient needs for DME, home health, value-added services, and any other necessary resources
  • Communicates these needs to the appropriate person (i.e., Social Worker, clinic staff, etc.) or addresses them per process
  • Collaborates with the nurse manager to recommend policies, procedures and standards which affect the care of the patient with high-risk chronic disease diagnoses such as CHF, IHD, COPD/asthma and diabetes
  • Performs all other related duties as assigned
  • I.e
  • IV Insertion with hydration fluid administration, wound care, dressing changes, suture removal, insertion and removal of urinary catheters, etc.

LVN Charge Nurse

LVN Med Surg Trauma Telemetry, Medical City Hospital
North Hills, Texas
12.2022 - 11.2023
  • Working with Adults with Developmental Disabilities
  • Completed patient assessment, medication administration, wound care, treatments, physician rounds, performed skilled nursing duties under the direction of the facility physician and RN
  • Geriatric Facility LVN Charge Nurse: Completed patient assessment, medication administration, wound care, treatments, physician rounds, and performed skilled nursing duties under the direction of the facility physician and RN
  • Field LVN: Complete patient assessment, patient/family education, medication administration, documentation, data entry and continuous care of the dying patient
  • Performed skilled nursing procedures under the direction of the Hospice Physician
  • Patient/Family/Community Liaison
  • CQI Nurse: Performing routine and continual quality assurance and chart auditing functions
  • Parking Administration to review and modify policy and procedure when necessary to meet State, Federal and Program requirements
  • Participate in updating agency "Resource Data Base." Assist with Inservice and educational events within the agency
  • Working knowledge of Specifications and Guidelines regarding HEDIS, Stars
  • InterQual, CMS medical necessity criteria
  • Customer Service Specialist, Assist in the determination of predictable healthcare needs of clients within structured healthcare settings who are experiencing common, well- defined health problems with predictable outcomes
  • Utilize a systematic approach to provide individualized, goal directed, and age specific care
  • Collect data and perform focused nursing assessments
  • Participate in the planning of nursing care needs for patients, and in modifying the nursing care plan for assigned patients
  • Implement appropriate aspects of care within the LVN scope of practice, including compliance with other laws applicable to the practice setting
  • Implement the teaching plan for patients with common health problems and well-defined learning needs
  • Provide direct basic care to assigned multiple patients in a structured setting
  • Assist in the evaluation of the patient’s responses and outcomes to therapeutic interventions
  • Utilize a problem-solving approach as the basis for decision making in practice.

Trauma Registrar Abstractor

HCA Parallon
, Texas
10.2021 - 12.2022
  • Abstracts physiological and anatomical data on trauma patients for inclusion into a trauma data collection system
  • Performs identification, prioritization, and injury coding of trauma patients for inclusion into a trauma data collection system
  • Performs duties to support the abstraction of quality trauma data for use locally, statewide, and nationally
  • Performs other trauma registry duties as may be required per the contract
  • Always maintain confidentiality and security of patient data
  • Abstracts data from the medical record according to the requirements of the hospital, state and national trauma registry data definitions including demographic characteristics, prehospital information, initial hospital treatment, operating room usage, outcome, and final disposition
  • Participates in periodic quality reviews
  • Interacts in a positive manner with client(s)
  • Remotely accesses electronic health records and trauma data collection systems
  • Can code in ICD-10-CM specific to injuries and mechanism of injuries
  • Can code in ICD-10-PCS
  • Can assign severity of injury utilizing the AAAM Abbreviated Injury Scale
  • Able to analyze and process meticulous information
  • Able to read and understand data definitions using a standard data dictionary
  • Initiative-taking and able to work independently
  • Amazingly comfortable working with technology and personal computer

Clinical Investigator

OPTUM
11.2018 - 04.2019
  • Waste, Abuse and Fraud, E&I and MMR, Performs clinical coverage review of CPT and HCPCS coded claims in a telecommuting work environment determining payment recommendation
  • Determines appropriate level of service utilizing Evaluation and Management Coding principles
  • Ensures adherence to state and federal compliance policies, reimbursement policies and contract compliance
  • Responsible for Clinical and Coding expertise in the application of medical and reimbursement policies within the claim adjudication process through file review
  • O This could include Medical Director/physician consultations, interpretation of state and federal mandates, applicable benefit language, medical and reimbursement policies and consideration of relevant clinical information
  • Performs clinical coverage review of post-service, pre-payment claims, which requires interpretation of state and federal mandates, applicable benefit language, medical & reimbursement policies, coding requirements and consideration of relevant clinical information on claims with aberrant billing patterns
  • Performs clinical coding review to ensure accuracy of medical coding and utilizes clinical expertise and judgment to determine correct coding & billing
  • Identifies aberrant billing patterns and trends, evidence of fraud, waste, or abuse, and recommends providers to be flagged for review
  • Maintains and manages daily case review assignments, with accountability to quality and productivity standards
  • Medicare Advantage, Original Medicare and or Medicaid appeal regulations
  • Provides clinical support and expertise to the other investigative and analytical areas
  • Participates in team and network meetings, engaging in a collaborative work environment
  • Medicare claim process and plan rules along with working with of ICD 9, ICD10
  • Serves as a clinical resource to other areas within the clinical investigative team

LVN II

Baylor Scott and White, HTPN Liver Consultants of Texas
06.2018 - 10.2018
  • Implements the nursing plan of care and measures to promote a safe environment for patients
  • Accepts only those nursing assignments that take into consideration client safety and that are commensurate with the nurse's educational preparation, experience, knowledge, and physical and emotional ability
  • Administers medications and IV therapy in accordance with the regulatory requirements
  • Texas Board of Nursing and Baylor Scott and White Health policies and procedures
  • Transition Care Management Provides telephonic post-discharge support to assist the defined population of patients in meeting short and long-term goals with regards to their overall well-being
  • The TCC may collaborate with other care team members such as home health providers to avoid redundant telephonic follow up and coordinate care
  • Coordinates comprehensive post discharge health care services, support programs, and referrals for community-based services
  • Reports and documents patient status, nursing care rendered, physician, and dentist or podiatrist orders, and administration of medication and treatments and patient responses
  • Observes patients, symptoms, signs and progress and report to Physicians
  • Uses observational data in working cooperatively with other health team members in modifying plans of care
  • Obtains instruction and supervision as necessary when implementing nursing procedures or practices
  • Utilizes a systematic approach to provide individualized, goal-directed nursing care
  • Attends educational meetings and conferences to maintain and enhance Nursing skill
  • Clinical competence and leadership skills for professional growth and development
  • Makes a reasonable effort to obtain orientation/training for competency when encountering new equipment and technology or unfamiliar care situations
  • Receives and transcribes Physicians' Orders received by telephone
  • Interacts with patients and families in a professional manner; and explains treatments, procedures, and Nursing care plan
  • Maintains clean and efficient patient environment such as carefully removing soiled linen, disposing of waste, and maintain
  • Equipment as required.

Licensed Vocational Nurse

Mesa Springs Hospital
Fort Worth, TX
07.2017 - 02.2018
  • Support the organization, program, and unit philosophy of care
  • Works with chemical dependency, dual diagnosis, psychiatric and geriatric patients
  • Coordinate and deliver quality general and psychiatric nursing care to patients
  • Ensure medical Orders are followed, initiate, and follow treatment planning
  • Patient assessments, family motivations, treatment planning and communication with external review organizations or comparable entities
  • Function as a patient advocate always.

HEDIS

NURSE REVIEWER, Cigna
Irving, TX
09.2015 - 02.2017
  • The HEDIS Reviewer works under the direction of the HEDIS Clinical Lead and other CIGNA personnel
  • This is a remote based position and the HEDIS reviewer is responsible for working independently to review and abstract pertinent medical record information in accordance with the HEDIS Technical Specifications
  • The HEDIS reviewer is responsible for setting-up and maintaining their own schedule, to include contacting their assigned offices to conduct the HEDIS review
  • The information to be abstracted will be obtained from medical records copied from physician offices/healthcare facilities and data entered the HEDIS Software
  • All medical records that are copied or received must be kept confidential, in accordance with federal and local requirements
  • HEDIS Reviewer must be able to attain an inter- rater reliability score of 95% or higher to remain eligible for continued employment for the duration of the project
  • Additionally, the HEDIS Reviewer may collaborate with non-clinical personnel regarding collection of medical records from physician offices for additional medical record pursuits or may collect the information themselves and other duties as assigned
  • This assignment would require travel to and from provider offices daily and could possibly require overnight travel on occasion, with advance notice
  • Coding and abstracting CPT, ICD9, ICD10
  • DRG, HCPCS
  • Responsible for the supervision of Care Managers in Oklahoma, Texas, Kansas, Arkansas, and Missouri
  • Maintains education/knowledge base of HEDIS/STARs standards and guidelines
  • This is a remote based position and the HEDIS reviewer is responsible for working independently to review and abstract pertinent medical record information in accordance with the HEDIS Technical Specifications
  • Skills Used: Personal computers, self-scheduled, excel spreadsheets
  • HEDIS Abstractor, Field Reviewer
  • Change Health Care/Altegra

Quality Coordinator

HEDIS
10.2016 - 10.2016
  • Identify appropriate information from medical records according to NCQA HEDIS Technical
  • Specifications and Change Healthcare guidelines
  • Enter data into Change Healthcare proprietary software
  • Maintain accuracy thresholds as set forth by Change Healthcare
  • Check chart assignments every day and accurately report all hours worked on a weekly basis
  • Report work-related concerns to assigned Clinical Advocate and, if not adequately addressed, to Sr
  • Manager of Clinical Operations
  • Comply with HIPAA laws and regulations
  • Participate in testing and training as required by the Company.

United Health Group, Well Med
Fort Worth, TX
02.2015 - 10.2015
  • Analyze data, evaluate data integrity and data deficits and document findings
  • Analyze and trend HEDIS/STAR rates, identify barriers to improvement of rates and create interpretive exhibits
  • Obtains quality detail report and flags patient's charts with missing measures
  • Used ePRG to provide reports
  • Works closely with local leadership to execute quality strategies
  • Supports and assists PCPs/clinics with quality data collection
  • Provides reports and monitors performance at local level
  • Engages PCP and clinic staff in developing strategies to close quality gaps
  • Ensures accurate and adequate payment based on expected medical costs
  • Supports and improves communications between market and corporate departments
  • Maintains education/knowledge base of HEDIS/STARs standards and guidelines.

Assistant Director of Nursing, Staff Developer

DS, Mira Vista Court
Fort Worth, TX
02.2014 - 02.2015
  • Of Nursing with overall management of the Nursing department
  • Assist in maintaining quality nursing care for all residents
  • Participates and assists in departmental studies and projects as assigned
  • Performs chart audits, MAR, and Treatment reviews
  • Assists in assessing learning needs of personnel to meet the needs of the consumer, organization, and employee
  • Participates in the quality assessment and improvement process and activities
  • May serve as facility QI Coordinator
  • Member of QI Committee
  • Abstracts statistical data for discharge records in accordance with the Uniform
  • Hospital Discharge Data Sets (UHDDS) standards, using the hospital's computer
  • Abstracting system
  • Follows Facility and Department policies and procedures
  • Participates in coding education programs
  • Maintains current and accurate
  • Knowledge of coding procedures and guidelines
  • Maintains current MDS status of each patient/resident in accordance with state and federal guidelines as required under the Omnibus Budget Reconciliation Act (OBRA)
  • Medicare PPS and any Medicaid payment system as applicable
  • Maintain all staffing and development processes
  • Serve as Director of Nursing is absence of the Director
  • Supervised and assessed vital changes in residents’ condition by monitoring vital signs, symptoms and test results Participates in the quality assessment and improvement process and activities
  • Served as facility QI Coordinator
  • Member of QI Committee
  • Abstracts statistical data for discharge records in accordance with the Uniform
  • Hospital Discharge Data Sets (UHDDS) standards, using the hospital's computer
  • Abstracting system
  • Follows Facility and Department policies and procedures
  • Participates in coding education programs
  • Maintains current and accurate
  • Continually documenting Member response to plan and interventions
  • Acting as
  • Member/staff/community liaison
  • Development of members transition process to home and or long-term care
  • Knowledge of coding procedures and guidelines
  • Ensures accurate and adequate payment based on expected medical costs
  • Maintains current MDS status of each patient/resident in accordance with state and federal guidelines as required under the Omnibus Budget Reconciliation Act (OBRA)
  • Medicare PPS and any Medicaid payment system as applicable
  • Serve as Director of Nursing is absence of the Director.

LVN/Nursing Assessment Coordinator

City view Care Center
Fort Worth, TX
11.2011 - 04.2014
  • Provide skilled professional nursing care to patients on inpatient units: express recovery and long-term care
  • MDS nurse
  • New admit and intake nurse
  • Document and record patients’ health status and nursing care
  • Participate in multidisciplinary care rounds
  • Healthcare experience to include experience in a managed care setting
  • Experience with data analysis/quality chart reviews
  • Must be able to review data and provide recommendations for improvement
  • Experienced using Microsoft office applications, including databases, word-processing, and excel spreadsheets
  • Supervise the care provided by nursing aides.

LVN Clinic Nurse, Med-Surgery, Unit

City view Care Center
Fort Worth, TX
04.2012 - 12.2012
  • Delivery of healthcare to infants, children, adolescents, and geriatrics
  • Assist with routine and acute clinic visits
  • Assist with minor office procedures and tests
  • Schedule routine and annual appointments
  • Coordination of HEDIS and STARs data gathering process within the clinic setting
  • Supports and improves communications between market and corporate departments
  • Maintains education/knowledge base of HEDIS/STARs standards and guidelines
  • Performs all other related duties as assigned
  • Assist coordinator or manager with administrative duties as assigned
  • Healthcare experience to include experience in a managed care setting
  • LVN assists physicians with examinations, treatments and special procedures and performs services requiring technical and manual skills as directed by the Registered
  • Nurse
  • LVN administers medication, performs treatments and patient care responsibilities as prescribed
  • LVN assists with admitting, discharging, and transferring of patients.

Education

Certified Professional Coder (CPC) - Certified Professional Coder (CPC)

AAPC
true
01-2025

License -

Texas State Board of Nursing
09.2011

Vocational -

Concorde Career Institute
08.2010

High school diploma - Early Childhood Development

Tarrant Community College
02.2000

Lamar University -

Lamar University
05.1984

Skills

  • CPT Coding Accuracy
  • ICD-10
  • Insurance Eligibility Verification
  • HEDIS Data Analysis
  • Managed Care Coordination
  • NCQA Standards
  • MDS
  • Medical terminology
  • Typing
  • Windows
  • Healthcare Coding Expertise
  • Infection Control Training
  • Nursing
  • Patient Medical Records Management
  • Quality Management
  • Healthcare Billing Expertise
  • Employee Orientation
  • Experienced in EMR Management

Certification

  • Medical Billing Certification, 09/11, Present
  • LVN, 09/11, Present
  • AED Certification
  • CPR Certification
  • Epic Certification

Personal Information

Title: LVN

Assessments

Medical Billing, Proficient, 04/20

Timeline

Healthcare Coordinator, LVN

Wellmed/USMD
09.2023 - Current

LVN Charge Nurse

LVN Med Surg Trauma Telemetry, Medical City Hospital
12.2022 - 11.2023

Trauma Registrar Abstractor

HCA Parallon
10.2021 - 12.2022

Clinical Investigator

OPTUM
11.2018 - 04.2019

LVN II

Baylor Scott and White, HTPN Liver Consultants of Texas
06.2018 - 10.2018

Licensed Vocational Nurse

Mesa Springs Hospital
07.2017 - 02.2018

Quality Coordinator

HEDIS
10.2016 - 10.2016

HEDIS

NURSE REVIEWER, Cigna
09.2015 - 02.2017

United Health Group, Well Med
02.2015 - 10.2015

Assistant Director of Nursing, Staff Developer

DS, Mira Vista Court
02.2014 - 02.2015

LVN Clinic Nurse, Med-Surgery, Unit

City view Care Center
04.2012 - 12.2012

LVN/Nursing Assessment Coordinator

City view Care Center
11.2011 - 04.2014

Certified Professional Coder (CPC) - Certified Professional Coder (CPC)

AAPC

License -

Texas State Board of Nursing

Vocational -

Concorde Career Institute

High school diploma - Early Childhood Development

Tarrant Community College

Lamar University -

Lamar University

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Lisa Milton