Maria C Killgore
Douglasville,PA
Summary
An organized professional registered nurse with over 30 years experience in various health care settings. Strong understanding of regulatory requirements, clinical assessment skills, investigating via medical records. Strong ability to quickly analyze and interpret data. Wide knowledge of health care services, delivery, and reimbursement.
Overview
43
43
years of professional experience
Work History
Quality Management Specialist RN
Independence Blue Cross
Philadelphia, PA
08.2021 - Current
- Addressing regulatory and accreditation requirements for NCQA standards.
- Analyze reports, coordinate and run meetings, and participate in department meetings.
- Monitor all NCQA accreditation status for all PA and NJ health plans.
- Collaborate with the Delegation department to gather information and documents for NCQA accreditation surveys.
- Coordinate monthly, or more frequent, meetings with the delegation department.
- Track and update Quality Management work plans.
- Review and investigate occurrences and quality of care complaints.
- Annually review QM policies and procedures.
- Create new desk references, work flows, as needed.
- Medical record review for medical occurrences, clinical complaints, drug utilization review, nursing home violations and complaints.
Clinical Reimbursement Coordinator
Genesis Healthcare System
Norristown, PA
02.2019 - 08.2021
- Also known as RNAC - Registered Nurse Assessment Coordinator, or MDS coordinator - Minimal Data Set
- Good knowledge of Medicare, Medicaid, Managed insurances
- Work closely with the business office for end of month billing and insurance issues.
- Daily contact with Physical Therapy department for utilization management of residents and to determine the need for liability letters.
- Direct relationship with the Nursing department for assessment information about residents, collaboration on care plans, and performing education on MDS documentation
- Organizing intradepartmental meetings with nutrition, physical therapy, nursing, business office, and the admissions coordinator for continued monitoring of residents and MDS completion.
- ICD 10 coding on residents charts for billing, MDS documentation. Coding on admission as adjusting as needed.
- Case Mix index reports - for facility reimbursement
- Keeping track of Physician Certifications Part A and B
- Compiling documentation for surveys and audits
Independent Contractor
Guardian Nurses
Philadelphia, PA
06.2017 - 01.2019
- Provide medical advocacy services for clients.
- Attending physician visits to explain medical terminology and provide patient support.
- Provide in-depth education on the clients diagnosis, potential procedures, and expected outcome.
- Instructions related to treatment plan, follow up visits, and what to expect during the treatment process.
Various Roles
Independence Blue Cross
Philadelphia, PA
08.2005 - 12.2016
- CLINICAL SERVICES COMPLIANCE SPECIALIST 2013 - 2016
- Role supporting the clinical programs provided by the company Case Management department.
- Developed and created forms such as audit tools, quick reference guides, and note templates.
- Performed audits for clinical Staff per NCQA guidelines, department policy and legal guidelines.
- Monitored department audit trends.
- Developed and designed educational tools for training new hire classes and refresher classes.
- Developed a Share Point site for reference materials, policies, and procedures.
- Stop Loss - Assessment and analytical skills used to review high claims for external Stop Loss insurance carriers.
- CASE MANAGEMENT 2008 - 2013
- Provide telephonic Case Management and Disease/Condition Management to members.
- Assessed needs of the member.
- Implemented and evaluated member centric plan of care through interventions such as education, motivational interviewing, and providing resources.
- Gap in care approach was used to identify and manage members with chronic conditions.
- CONCURRENT MEDICAL UTILIZATION REVIEW 2005 - 2008
- Facilitated concurrent utilization medical reviews - telephonic and onsite.
- Coordinated discharge planning to various settings including acute rehab, LTAC, SNF, and home care
- Evaluated DME precertification needs.
- Proficient in the used of medical policy and Interqual criteria
Acute Care Registered Nurse
Various Hospitals
Philadelphia, NY
10.1980 - 07.2005
- PHOENIXVILLE HOSPITAL, Phoenixville, PA 2001 - 2005
- ABINGTON MEMORIAL HOSPITAL, Abington, PA 1992 - 2001
- WARMINISTER HOSPITAL, Warminister, PA 1990 - 1992
- HOLY REDEMEER HOSPITAL, Meadowbrook, PA 1987 -1989
- FRANKFORD HOSPITAL, Philadelphia, PA 1980-1987
Education
Bachelor of Science - Nursing
University of Phoenix
Phoenix, AZ04-2009
Associate of Arts - Liberal Arts And Sciences
Penn State University
Abbeville, AL05-1983
Nursing - Nursing
Frances Perkins Academy
Philadelphia, PA05-1983
Skills
- Quality Management
- Regulatory standards - NCQA, PDPM, CMS
- Internal Auditing
- SOP Development - desk reference, job aids
- Documentation Control
- Relationship Building
- Written Communication
- Adaptability and Flexibility
- Professional Demeanor
- Decision-Making
- Interpersonal Communication
- Self Motivation
- Goal Setting
- Team Collaboration
- Problem-Solving
- Time Management
- Organizational Skills
- Active Listening
- Excellent Communication
Timeline
Quality Management Specialist RN
Independence Blue Cross
08.2021 - Current
Clinical Reimbursement Coordinator
Genesis Healthcare System
02.2019 - 08.2021
Independent Contractor
Guardian Nurses
06.2017 - 01.2019
Various Roles
Independence Blue Cross
08.2005 - 12.2016
Acute Care Registered Nurse
Various Hospitals
10.1980 - 07.2005
Bachelor of Science - Nursing
University of Phoenix
Associate of Arts - Liberal Arts And Sciences
Penn State University
Nursing - Nursing
Frances Perkins Academy
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