Summary
Overview
Work History
Education
Skills
Personal Information
Timeline
Generic

Nancy Young

Tipp City

Summary

Organized team leader builds positive rapport, inspires trust and guides teams toward achievement of organizational goals. Strong facilitator adept at working cross-departmentally with co-management and top-level leadership. Excellent trainer and mentor.

Overview

31
31
years of professional experience

Work History

Clinical Appeals Team Lead

CareSource Management Group
08.2012 - Current
  • Supervise the day to day operations of Clinical Appeals Nurses and Appeal Coordinators
  • Conduct annual reviews and performance evaluations
  • Ensure compliance with all regulatory, contractual and accreditation requirements
  • Prepare for NCQA audits for Medicaid and Marketplace lines of business
  • Serve as the point person for NCQA onsite audits
  • Collaborate with Managers, Medical Directors, Pharmacists, Legal, Regulatory and other internal departments to ensure appeals and state/fair hearings are processed appropriately
  • Oversight of the audit process for clinical appeals and state hearings
  • Process all external review requests for Medicaid and Marketplace product lines
  • Assist Provider Claim Appeals team to distinguish claim versus clinical appeals
  • Develop and implement SOPs and training tools related to all jobs
  • In collaboration with the Clinical Appeals Managers/Directors and Medical Directors, generate, monitor and analyze reports related to key statistics and other reports deemed necessary
  • Review, track and trend Quality of Care issues and sentinel events
  • Ensure all clinical quality issues are resolved within specific timeframes as indicated by the states served and programs therein, CMS and all accrediting entities
  • Oversight of the hybrid chart review for HEDIS
  • Assist with Encounter Data Validation (EDV) studies.

Patient Care Coordinator

CareSource Management Group
10.2006 - 09.2007
  • Process reviews of inpatient admissions using Milliman criteria
  • Coordinate and facilitate discharge to an appropriate level of care in a timely and cost-effective manner
  • Identify and refer quality issues to the Quality Improvement Department
  • Identify and refer members to Case Management, when appropriate
  • Provide direction to non-clinical medical management staff.

Supervisor, Medical Management

Summit Insurance Company
03.2001 - 08.2006
  • Oversee the collection of health data from Medical Management and SummitComp for monthly reporting, pharmacy utilization and quality indicators
  • Manage the activities of the Appeals Coordinator and Disease Management & Underwriting Coordinator
  • Conduct annual reviews/performance appraisals
  • Perform quarterly audits for Utilization Management and SummitComp to assure URAC standards are met
  • Supervise the claims payment processes for Medical Management
  • In charge of gathering all necessary data for monthly reports (Length of Stay, Days per Thousand, etc.)
  • Responsible for preparing agenda, researching new technology for presentation, and taking minutes for the UM/PT Committee meetings
  • Oversee the use of the MHS software system
  • Supports MHS users by troubleshooting and resolving MHS system related issues
  • Collaborate with the IS/IT department with annual software upgrades
  • Perform review of claims for historical auditing and appropriate diagnosis coding in conjunction with the Medical Director
  • Initiates physician contact, when necessary, to resolve disputes on utilization and quality issues
  • Assist in renewal and underwriting functions by developing reports and conferring with the Medical Director to assign claim costs.

Medical Management Coordinator

Summit Insurance Company
04.1996 - 03.2001
  • Perform telephonic precertification, prospective, concurrent and retrospective review of cases using Interqual criteria
  • Oversee the development of Summit’s Fee Schedule by reviewing national databases of fees
  • Set individual fees when necessary to process claims
  • Responsible for reports to gain all data necessary for annual provider profiling
  • Assist in the interpretation of contract language, to determine whether a service meets criteria as a covered benefit of plan and responsible for maintenance of the Benefits Administration Manual
  • Perform review of claims for historical auditing and appropriate diagnosis coding in conjunction with the Medical Director
  • Initiates physician contact, when necessary, to resolves disputes on utilization and quality
  • Negotiate with non-contracted providers to obtain fee reductions for services.

Utilization Review Nurse

Wright Health Associates
07.1995 - 04.1996
  • Responsible for precertification of outpatient and inpatient procedures, concurrent phone review for numerous Dayton and out-of-area hospitals
  • Conduct on-site concurrent review at three area hospitals
  • Use of Milliman and Robertson (M&R) and Managed Care Appropriateness Protocol (MCAP) for precertification and continued length of stay criteria.

Staff Nurse

Children’s Medical Center
07.1993 - 07.1995
  • Responsible for providing direct nursing care to pediatric and NICU patients.

Education

BSN -

Wright State University
Dayton, Ohio

Skills

  • MCG Certified
  • Team Leadership
  • Time Management
  • Staff Training and Development
  • Policy Implementation
  • Work Planning and Prioritization
  • Daily workflow improvement

Personal Information

Title: RN, BSN

Timeline

Clinical Appeals Team Lead

CareSource Management Group
08.2012 - Current

Patient Care Coordinator

CareSource Management Group
10.2006 - 09.2007

Supervisor, Medical Management

Summit Insurance Company
03.2001 - 08.2006

Medical Management Coordinator

Summit Insurance Company
04.1996 - 03.2001

Utilization Review Nurse

Wright Health Associates
07.1995 - 04.1996

Staff Nurse

Children’s Medical Center
07.1993 - 07.1995

BSN -

Wright State University

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