Megan Pfenning
Summary
Registered Nurse with 13 years of acute care case management experience specializing in medical necessity review, regulatory compliance, utilization analysis and care coordination. Seeking to leverage clinical documentation expertise and risk-identification skills in Fraud, Waste and Abuse Analyst role.
Overview
17
17
years of professional experience
1
1
Certification
Work History
Registered Nurse Case Manager, ACM
Allina Health- Abbott Northwestern Hospital
Minneapolis, MN
01.2013 - Current
- Diligent monitoring of 17-31 cases daily to support cost containment by reducing avoidable inpatient delays.
- Collaborate with care team to ensure appropriate resource utilization for complex cases, avoiding duplication of services, intervening as needed based off clinical expertise.
- Evaluate healthcare needs, treatment goals and available resources of each patient and connect to care across all healthcare settings, ensuring continuity and preventing waste.
- Advocate for patients by verifying interventions meet treatment goals while identifying insurance coverage limitations and medical necessity.
- Developed professional relationships with community partners and vendors to enhance available services and equipment for patients transitioning from acute care setting.
- Analyze utilization data to identify trends, identify and escalate documentation gaps to mitigate inappropriate admissions and reduce financial risk.
- Contribute to cost savings by evaluating complex cases to determine medical necessity and appropriate levels of care, ensuring quality assurance and compliance with payer regulations.
- Reduce hospital readmissions with proactive identification of high-risk patients and implementation of targeted interventions.
- Promote interdepartmental collaboration to streamline workflow, resulting in improved efficiency and patient outcomes.
- Serve as a liaison between healthcare providers, insurance companies, and patients for efficient resolution of coverage issues or denials.
- Obtain prior authorization of multiple different payers with awareness of appropriate ICD-10 code selection.
- Assist in maintaining regulatory compliance by staying up-to-date on Medicare, Medicaid, and commercial insurance requirements for utilization review activities.
- Participated in performance improvement projects aimed at streamlining processes related to UM/UR and case management.
Registered Nurse, School Nurse
Isd 196
10.2021 - 06.2023
- Conducted comprehensive assessments to evaluate student conditions and treatment efficacy.
- Improved documentation processes, ensuring compliance with regulatory standards HIPPA and FERPA and enhancing efficiency.
- Collaborated with interdisciplinary teams to develop comprehensive treatment plans for medically complex students with multiple comorbidities.
- 3rd party billing to Medicaid for nursing services rendered for eligible students
- Review and analysis of infections and reporting to Minnesota Department of health as required
- Maintained regulatory compliance in documentation standards for SPED, IEP, 504s per Dept of Education requirements.
Circulating Nurse, Operating Room
Allina Health
Abbott Northwestern Hospital, Minneapolis MN
01.2011 - 01.2013
- Evaluated surgical supplies inventory, ensuring availability for seamless operations for multiple cases, or lengthy, complex cases.
- Streamlined operating room setup for faster procedure turnaround times, ensuring timely patient care.
- Promoted a positive work environment within the operating room by fostering strong teamwork among all staff members involved in each case.
- Demonstrated adaptability to various types of surgeries, swiftly learning new techniques when required.
- Supported ongoing education efforts within the surgical department, participating in training sessions and sharing knowledge with colleagues for continuous improvement.
- Maintained comprehensive documentation of all surgical processes, enhancing communication among medical professionals involved in each case.
Telemetry Registered Nurse
Allina Health
Abbott Northwestern Hospital, Minneapolis
01.2009 - 01.2011
- Developed and implemented individualized care plans based on patient assessments and telemetry data.
- Educated patients and families on cardiac health management, improving adherence to treatment plans.
- Prevented life-threatening complications by quickly recognizing early warning signs of deterioration in critically ill patients under close observation.
- Collaborated with interdisciplinary healthcare teams to develop and implement individualized care plans for patients with complex conditions.
- Managed complex assignment with varying acuity levels, effectively prioritizing care needs and allocating resources as necessary.
- Facilitated seamless transitions of care from ICU to telemetry unit by coordinating necessary equipment, resources, and personnel.
- Played a key role in quality improvement initiatives designed to enhance clinical processes within the unit.
Education
Master of Science - Holistic Health Studies
St Catherine University
St Paul, Minnesota 12-2023
Bachelor of Science - Nursing
Minnesota State Moorhead
Moorhead, MN12-2012
Associate of Applied Science - Nursing
Inver Hills Community College
12-2008
Skills
- Case evaluation
- Strong clinical judgment
- Pattern recognition
- Service coordination
- Attention to detail
- Insurance verification
- Documentation and reporting
- Records analysis
- Medicare, Medicaid, Waivers
- Understanding of reimbursement rules, DRGs, Medical necessity criteria and cost drivers
Certification
- Certified Case Manager- ACM, American Case Management Association
Timeline
Registered Nurse, School Nurse
Isd 196
10.2021 - 06.2023
Registered Nurse Case Manager, ACM
Allina Health- Abbott Northwestern Hospital
01.2013 - Current
Circulating Nurse, Operating Room
Allina Health
01.2011 - 01.2013
Telemetry Registered Nurse
Allina Health
01.2009 - 01.2011
Master of Science - Holistic Health Studies
St Catherine University
Bachelor of Science - Nursing
Minnesota State Moorhead
Associate of Applied Science - Nursing
Inver Hills Community College