Detail-oriented Registered Nurse with experience in utilization review, prior authorization, and clinical documentation improvement in acute care settings. Skilled in concurrent chart review, identifying documentation gaps, and collaborating with providers to ensure accurate coding, severity of illness capture, and regulatory compliance. Proficient in applying medical necessity criteria and supporting documentation integrity to optimize patient outcomes and reimbursement accuracy.
***Worked x2 at BMC from 01/2022-07/2023 and 06/2024-12/2024)
Clinical Documentation Improvement (CDI)
Concurrent & Retrospective Chart Review
Provider Query Process & Documentation Clarification
DRG Validation & Optimization
Severity of Illness (SOI) / Risk of Mortality (ROM)
ICD-10-CM/PCS Knowledge
Utilization Review & Medical Necessity (InterQual/Milliman)
Prior Authorization Review
Denial Prevention & Compliance (CMS Guidelines)
EPIC, Cerner, Meditech, Soarian
•Improved documentation accuracy by consistently identifying gaps and initiating provider queries, supporting appropriate DRG assignment and coding specificity
• Contributed to reduction in claim denials by ensuring alignment with medical necessity criteria and payer requirements
• Enhanced documentation quality through effective provider collaboration, improving severity of illness (SOI) and risk of mortality (ROM) capture
• Supported timely chart review processes, maintaining efficiency while ensuring compliance with regulatory standards
• Improved care coordination and documentation consistency across interdisciplinary teams
• Strengthened compliance with payer requirements through detailed documentation review and follow-up