Summary
Overview
Work History
Education
Skills
Certification
Timeline
Generic

Nancy Simon

Port Saint Lucie

Summary

Healthcare professional skilled in auditing medical records and ensuring compliance with industry standards. Proven ability to enhance process efficiency and accuracy in healthcare documentation. Valued team collaborator focused on delivering results and adapting to dynamic environments. Adept at data analysis and regulatory compliance.

Overview

11
11
years of professional experience
1
1
Certification

Work History

Nurse Auditor

CSTS/Ultimate Health Plans
12.2022 - Current
  • Authorization Denials
  • Prepare a clinical reconsideration/appeal letter to submit to the payer based on the evidence in the patient’s medical records to justify either an acute level of care or skilled level of care (based on results from either MCG or InterQual review).
  • Medical Necessity Denial Reviews
  • Prepare a clinical reconsideration/appeal letter to submit to the payer based on the evidence in the patients’ medical records that supports the necessity for denied services.
  • Other Denial Reviews for Appeal:
  • DRG Downgrades
  • MAC & RAC Audits
  • Payer Utilization Review Audits
  • Experimental Procedures
  • Charge Audits

Care Coach/Case Manager

Humana
10.2021 - 12.2022
  • Complete telephonic health and psychosocial assessments for Risk and managed care members.
  • Identify barriers, plan patient-centered interventions, and evaluate plans of care.
  • Utilizes a collaborative process of assessment, planning, facilitation, and advocacy for options and
    services to meet an individual's benefit plan and/or health care needs through communication and
    available resources to promote optimal, cost-effective outcomes.
  • Complete medical necessity and level of care reviews for requested services using clinical judgment and
    refer to Medical Directors for review depending on case findings.
  • Efficiently balanced team and individual responsibilities and goals.
  • Assist members with physical, environmental, psychosocial, and health issues by coordinating with
    physicians and community organizations.
  • Continuous monitoring of patients to ensure progression towards desired goals for maintenance of
    multiple chronic conditions.
  • Following up with transitions of care to avoid readmissions, including review of medication
    reconciliations.
  • Telephonically assess Medicare, Medicaid, and Commercial to appropriately coordinate benefits
    Identify gaps in care and treatment, identify barriers and implement interventions to assist in maintaining
    wellness.

Detox/Psych Nurse

Neuropsychiatric Addiction Clinic
06.2019 - 10.2021
  • Conduct COWS and CIWA assessment, monitoring and communicate observations and findings with
    physicians and other members of the treatment team.
  • Administer Detox and Psychiatric medications as prescribed.
  • Monitor for seizures and adverse effects.
  • Conduct Groups to promote restoration of health, client and family education and serves as a client
    advocate.
  • Coordinate with Nursing Program Director, Medical Director, Executive Director, Social Workers,
    Pharmacist, and Case Managers to keep all informed of current departmental activities, plans, and
    developments through both oral and written reports.
  • Maintain medical charting.
  • Coordinate emergency medical care for medical and psychiatric emergencies.
  • Maintain and adheres to established infection control protocols.
  • Comply with all program policies and procedures, as well as all state and accreditation standards.
  • Consult with psychiatrists and other behavioral health staff in designing appropriate treatment plans for
    clients.

Geriatric Nurse/Licensed Practical Nurse

Port Saint Lucie Nursing
03.2018 - 10.2021
  • Provided proficient nursing care to geriatric patients; Thorough head-to-toe assessments, and health
    history, obtained and analyzed objective and subjective data.
  • (Lab reports, EKG, radiological exams, and symptoms.)
  • Developed patient-specific care plans
  • Maintained complete timely documentation
  • Interdisciplinary care- collaboration to optimize care and reduce inpatient length of stay
  • Patient advocate through education and patient-centered treatment development
    Patient education: diagnosis, treatment, lifestyle adjustments, medication management, and wound
    care/incision site care
  • Discharge planning and coordination of appropriate outpatient services
  • Preceptor for novice nurses and new team members.

Geriatric Nurse/Licensed Practical Nurse Supervisor

Rehabilitation Center at Jupiter Gardens
07.2014 - 03.2018
  • Supervised a 48-bed subacute rehabilitation unit in a 120-bed skilled nursing facility
  • Delegated and prioritized patient care assignments
  • Sought out avenues to improve quality and efficiency
  • Provide education and evaluation of nursing and patient care staff
  • Provided staff education on new equipment, supplies and services
  • Facilitated evidence-based research within the geriatric population
  • Ensured adherence to AHCA standards and company policies/procedures
  • Performed annual employee evaluations for subordinate clinical staff
  • Completed employee health screenings and maintained health records.

Education

Vocational - Licensed Practical Nursing

Academy of Nursing And Health Occupations
06.2014

Bachelor of Arts - Political Science

Florida Atlantic University
05.2009

Skills

  • Utilization Review
  • Case Management
  • Preparing and submitting Authorizations
  • Use of InterQual and/or MCG
  • Inpatient Clinical Experience
  • Strong analytical skills
  • Documentation review expertise
  • Electronic health records navigation
  • Medical coding proficiency
  • Attention to detail
  • ICD-10 coding
  • Billing procedures

Certification

LICENSES & CERTIFICATIONS, Licensed Practical Nurse (LPN), FL, license#: PN5216144

Basic Life Support (BLS), Body: AHA- American Heart Association, expires: 01/2026

Timeline

Nurse Auditor

CSTS/Ultimate Health Plans
12.2022 - Current

Care Coach/Case Manager

Humana
10.2021 - 12.2022

Detox/Psych Nurse

Neuropsychiatric Addiction Clinic
06.2019 - 10.2021

Geriatric Nurse/Licensed Practical Nurse

Port Saint Lucie Nursing
03.2018 - 10.2021

Geriatric Nurse/Licensed Practical Nurse Supervisor

Rehabilitation Center at Jupiter Gardens
07.2014 - 03.2018

Bachelor of Arts - Political Science

Florida Atlantic University

Vocational - Licensed Practical Nursing

Academy of Nursing And Health Occupations

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