Summary
Overview
Work History
Education
Skills
References
Timeline
Generic

Mayward Wynette Earl

McKinney,Texas

Summary

Dynamic Clinical Review Nurse with extensive experience in case management, utilization review, DRG reviews, and medical coding. Proven track record in enhancing patient care through interdisciplinary collaboration, discharge planning, and data analysis. Skilled in medical coding and committed to quality improvement, achieving a 98% quality score while ensuring HIPAA compliance.

Overview

13
13
years of professional experience

Work History

PAC Clinical Review Nurse

CareCentrix Healthcare
Hartford, CT
06.2024 - Current
  • Conducted telephonic reviews with assigned post-acute facilities to assess member status and validate continued stay appropriateness.
  • Executed utilization reviews for continued care at SNFs, IRFs, LTACHs, and Home Health using approved medical guidelines.
  • Evaluated medical necessity for services, treatments, and devices by applying clinical expertise and evidence-based criteria.
  • Completed case reviews and escalated determinations as necessary to meet contractual and regulatory turnaround time requirements.
  • Monitored patient length-of-stay metrics and identified cases at risk for exceeding expected LOS benchmarks.
  • Participated in interdisciplinary rounds to review patient progress, identify discharge barriers, and recommend actions for expedited care transitions.
  • Collaborated with physicians, case managers, social workers, and therapy teams to address clinical delays until safe discharge plans were established.
  • Reviewed medical records to assess management needs, clinical complexity, and factors contributing to prolonged length of stay.

Clinical DRG Nurse Auditor

Optum Healthcare
Eden Prairie, MN
01.2016 - 03.2024
  • Executed DRG validation for M&R, C&S, and E&I cases, ensuring accurate coding based on clinical support.
  • Conducted audit reviews on inpatient and outpatient claims using ICD 10 CM and ICD 10 PCS guidelines to identify overpayments.
  • Performed comprehensive DRG validation for Medicare, E&I, and C&S claims to detect up-coding and misrepresentation of services.
  • Conducted pre-bill and post-bill audits to uncover incorrect DRG assignments and missed CC/MCC opportunities.
  • Applied CMS and official coding guidelines to guarantee compliant coding practices.
  • Drafted denial letters utilizing precise verbiage assigned by diagnosis for healthcare facilities.
  • Identified and prevented healthcare fraud, waste, and abuse through analysis of claim data and CMS guidelines.

Prior Authorization/ Concurrent Review Nurse

Molina Healthcare
Irving, TX
07.2013 - 01.2016
  • Conducted prior authorization reviews per Molina policy for home health, inpatient, outpatient, adaptive aids, and DME supplies.
  • Met daily production metrics by applying clinical knowledge to assess medical necessity using MCG, InterQual, and Milliman criteria.
  • Collaborated with multidisciplinary teams to enhance patient care and abstracted data from medical records for medical necessity evaluations.
  • Engaged with MDs regarding denial issues and facilitated peer-to-peer processes for providers.
  • Assisted discharge planners in determining post-acute care needs for members.
  • Identified member benefits and eligibility while completing utilization reviews for new treatments or procedures.
  • Participated in interdepartmental collaborations to improve continuity of care across various services including Behavioral Health and Long-Term Care.
  • Maintained a quality score of 98% or better, completing objectives and documentation within three days.

Education

LVN/LPN State of Texas - CPC, CIC, CPMA

01.2026

ADN Program -

Collin County Community College
11.2013

LVN/LPN Program -

Dallas Nursing Institute
Dallas, TX
11.2009

Skills

  • Microsoft Office suite
  • Clinical software proficiency
  • HIPAA compliance
  • Medical coding expertise
  • Data analysis
  • Utilization review
  • Case management
  • Clinical assessment
  • Health education
  • Home healthcare
  • Ventilator care
  • Communication skills
  • Dementia care
  • Pediatric nursing
  • Clinical documentation
  • Quality improvement
  • Interdisciplinary collaboration
  • Clinical judgment
  • Medical record review
  • Evidence-based practice

References

References and Recommendation letters available upon request.

Timeline

PAC Clinical Review Nurse

CareCentrix Healthcare
06.2024 - Current

Clinical DRG Nurse Auditor

Optum Healthcare
01.2016 - 03.2024

Prior Authorization/ Concurrent Review Nurse

Molina Healthcare
07.2013 - 01.2016

LVN/LPN State of Texas - CPC, CIC, CPMA

ADN Program -

Collin County Community College

LVN/LPN Program -

Dallas Nursing Institute
Mayward Wynette Earl