Lisa White
Petoskey,MI
Summary
Dynamic and results-driven Medical Claim Review Appeal Nurse with a proven track record at Molina Healthcare. Expert in clinical assessment and regulatory compliance, achieving exceptional quality assurance in utilization management. Adept at leading teams and restructuring workflows to enhance performance, while maintaining meticulous documentation in electronic medical records.
Overview
9
9
years of professional experience
1
1
Certification
Work History
Medical Claim Review Appeal Nurse
Molina Healthcare
, MI
07.2024 - Current
- Responsible for the review of documentation to ensure medical necessity and the appropriate level of care, utilizing MCG/InterQual, state/federal guidelines, billing and coding regulations, and Molina policies; validate the medical record and claim submitted to support correct coding, to ensure appropriate reimbursement to providers.
- Performs clinical and medical reviews of retrospective medical claim reviews, medical claims, and previously denied cases in which an appeal has been submitted to ensure medical necessity, appropriate billing, and claims processing.
- Supplies criteria supporting all recommendations for the denial or modification of payment decisions.
Medicare Advantage Inpatient Preauthorization RN
Blue Cross Blue Shield of Michigan/Walker Health
, MI
12.2022 - 06.2025
- Perform prospective, concurrent, and retrospective reviews of inpatient admissions to ensure medical necessity. Consistently exceeds expectations of eight cases per day, as well as exceeds quality assurance of 95%.
- Analyze, research, respond to, and prepare documentation related to retrospective review requests in accordance with local, state, and federal regulatory, and designated accreditation standards.
- Maintained thorough, accurate and confidential documentation in electronic medical records.
Team Lead of Clinical Services
ISG
, MI
06.2016 - 12.2022
- Provide exceptional leadership to the national nurse review and national physician review nurses, ensuring 98% quality assurance on utilization reviews for auto injury claims. Supervising the clinical review departments to ensure turnaround times for reviews are completed within contractual agreements.
- Initiated monthly evaluations to provide feedback for each team member, to achieve excellent quality reviews for clients.
- Restructured quality assurance workflow for the national nurse review department.
Education
Associate Degree in Nursing -
Excelsior College
Albany, NY06-2011
Skills
- Medical claim review
- Clinical assessment
- Utilization management
- Electronic medical records
- Regulatory compliance
- Quality assurance
- Policy adherence
Certification
- RN Registered Nurse, Michigan
Timeline
Medical Claim Review Appeal Nurse
Molina Healthcare
07.2024 - Current
Medicare Advantage Inpatient Preauthorization RN
Blue Cross Blue Shield of Michigan/Walker Health
12.2022 - 06.2025
Team Lead of Clinical Services
ISG
06.2016 - 12.2022
Associate Degree in Nursing -
Excelsior College
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