Meribeth Cipriano
Killingworth,CT
Summary
Legal Nurse Consultant with over 35 years of experience, specializing in medical record analysis and compliance. Expert at enhancing medical record accuracy and clarity. Strong background in healthcare laws and regulatory compliance, contributing to effective case strategies.
Overview
36
36
years of professional experience
Work History
Lead Commercial Compliance Specialist
Emblem Health
New York City, NY
02.2024 - Current
- Conduct Regulatory Research and provide regulatory guidance of policies and programs.
- Ensure business areas and delegates understand and address all actionable memos or directives collect artifacts that demonstrate process, operations, trainings policies and procedures are updated.
- Researching and providing interpretation of guidelines and regulations
- Support business areas in creating and updating policies and procedures, trainings, reports and monitoring activities to ensure compliance
- Project Management oversight for regulatory compliance
Manager, Clinical Operations Delegation and Audit
Connecticare
08.2021 - 08.2023
- Managed a diverse team for delegation oversight, streamlining case management processes
- Developed National Committee for Quality Assurance (NCQA) and regulatory audit tools and reports, data aggregation and presentation of results for Case Management, Utilization Management and Key Performance Indicators.
- Collaborated with cross-functional teams to improve clinical operations and patient outcomes.
- Developed and implemented training programs to enhance team performance and compliance understanding.
Clinical Operations Delegation Manager
Connecticare
Farmington, CT
10.2019 - 08.2021
- Direct accountability for the oversite of utilization and care management delegated services follows NCQA, State and Federal standards.
- Process improvement
- Liaison between medical management, internal stakeholders, and vendors
- Conducted regular audits with review of policies, procedures and medical records of inpatient hospitalization, skilled nursing facility, durable medical equipment, behavioral health, outpatient neurological and orthopedic diagnostic testing.
- Monitor Corrective Action Plans
- Root Cause and Impact Analysis
- Liaison between medical management, internal stakeholders, and vendors
Senior Field Case Manager
Optum
Rocky Hill, CT
01.2014 - 05.2019
- Performed medical chart review of long term and short-term members for Medicare, and Commercial lines of business in skilled nursing facilities.
- Assisted to develop care plans and monitor progress towards goals.
- Developed presentation of clinical content to clinicians
- Collaborated with clinical team for care coordination and benefit coordination.
- Managed quality assurance program including on site evaluations, and aggregated data for HEDIS/STAR Quality Management
- Researched and implemented initiatives and provided continuous documentation improvement to promote quality and improve efficiency and timeliness.
- Co-managed team of 14 Professional staff members
Utilization Review Transition Case Manager
United Health Care
Rocky Hill, CT
09.2007 - 01.2014
- Performed medical chart review for acute inpatient hospital services and skilled nursing level of care and determined medical appropriateness of inpatient and outpatient services following evaluation of medical guidelines and benefit determination
- Case management, health education, and solved moderately complex problems
Discharge Case Manager
Hospital of St. Raphael's
New Haven, CT
01.2006 - 09.2007
- Evaluated medical necessity of admission and continued length of stay in the inpatient acute care setting
- Coordinated services of home care, durable medical equipment and facility placement
- Utilized medical management criteria appropriate for length of stay
Nurse Consultant
Aetna
Middletown, CT
06.1999 - 12.2005
- Coordinated and organized monthly Quality Advisory Committee meetings, liaison with physicians
- Conducted audits of core measures, abstraction and analysis of clinical data, barrier and root cause analyses, process improvement, outcome analysis, established goals and implement initiatives and quality interventions.
- Review of Health Delivery Organizations regarding surveys and audits against Medicare and State Regulations
- Performed benefit and medical chart reviews for member grievance and appeals and retrospective hospital inpatient stays, homecare, skilled nursing facilities, behavioral health, and durable medical equipment
- Developed, implemented and amended policies, procedures, and correspondence according to state, federal and regulatory standards.
Supervisor Prior Authorization and Treatment Planning
Anthem Blue Cross & Blue Shield
North Haven, CT
09.1994 - 06.1999
- Medical Chart analysis and audits, of outpatient services -durable medical equipment, rehabilitative services and infertility
- Continuous Quality Documentation Improvement
- Developed, implemented and amended policies, procedures, correspondence and forms according to state, federal and regulatory standards.
- Assessed contract liability
- Case Management
Supervisor Home Health Aides
Rutland Visiting Nurse Association
Rutland, VT
10.1993 - 09.1994
- Coordinated and managed of home health aides in the home care setting.
- Managed day to day operations, ensured adequate supplies and resources available and acted a clinical resource.
- Performed on site home care visits with staff
- Developed, implemented and amended policies, procedures
Home Care Case Manager
Olsen Kimberly Quality Care
Stratford, CT
10.1990 - 10.1993
- Provided onsite homecare visits for wound care, colostomies, paraplegics, stroke, cardiac and pulmonary diseases. And medication administration
Orthopedic and Pediatric Staff Nurse
St. Vincent's Medical Center
Bridgeport, CT
07.1989 - 10.1990
- Orthopedic, pediatric and general surgery patient care in the acute hospital setting
Education
Bachelor of Science - Nursing
Salve Regina University
Newport, RILegal Nurse Consultant Training -
Sacred Heart University
Fairfield, CTSkills
- - Regulatory Compliance
- Policy Development
- Auditing and Reporting
- Clinical process improvement
- Risk assessment
- Medical record review
Timeline
Lead Commercial Compliance Specialist
Emblem Health
02.2024 - Current
Manager, Clinical Operations Delegation and Audit
Connecticare
08.2021 - 08.2023
Clinical Operations Delegation Manager
Connecticare
10.2019 - 08.2021
Senior Field Case Manager
Optum
01.2014 - 05.2019
Utilization Review Transition Case Manager
United Health Care
09.2007 - 01.2014
Discharge Case Manager
Hospital of St. Raphael's
01.2006 - 09.2007
Nurse Consultant
Aetna
06.1999 - 12.2005
Supervisor Prior Authorization and Treatment Planning
Anthem Blue Cross & Blue Shield
09.1994 - 06.1999
Supervisor Home Health Aides
Rutland Visiting Nurse Association
10.1993 - 09.1994
Home Care Case Manager
Olsen Kimberly Quality Care
10.1990 - 10.1993
Orthopedic and Pediatric Staff Nurse
St. Vincent's Medical Center
07.1989 - 10.1990
Bachelor of Science - Nursing
Salve Regina University
Legal Nurse Consultant Training -
Sacred Heart University
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