Summary
Overview
Work History
Education
Skills
Timeline
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NATALIE LUHMAN

Greenville

Summary

My experience in the insurance industry has given me the ability to perform all types of clinical reviews from prior authorizations for medical outpatient, durable medical equipment, inpatient, skilled nursing facility, genetic testing; claims reviews; and appeals and grievances. I focus on quality.

Overview

24
24
years of professional experience

Work History

RN – UTILIZATION MANAGEMENT

Medasource/HNFS/TRICARE
05.2024 - Current
  • Utilization Management for TRICARE prior authorizations
  • Reviewing clinical documentation for determinations of preauthorizations for durable medical equipment; including wheelchairs, orthotics, CPAP, hearing aids, and many others for determinations of benefit
  • This is completed by utilizing TRICARE Policy Manuals, & TRICARE Operations Manual & review of clinical documentation
  • Skills Used: Nursing assessment, critical thinking, organizational skills, multi-tasking, MS Office

RN – MEDICARE APPEALS ANALYST

WPS Health Insurance
08.2021 - 05.2024
  • Review clinical documentation for first level provider appeals for medical necessity, correct coding, and Medically Unlikely Events (MUE) by using CMS Internet Only Manuals (IOMs), National Coverage Determinations (NCDs), National Correct Coding Initiative (NCCI), Local Coverage Determinations (LCDs), and Articles for both Medicare Part A, B of A, and Part B claims for procedures, medications, Inpatient Rehabilitation Facilities (IRFs), and two-midnight rule
  • Review of CPT/HCPCS codes and medical records
  • Utilizing many systems such as: FISS, MAS, Common Working File (CWF), MCSDT, and MFSDB to determine if the CPT/HCPCS can be approved
  • Act as next level of appeal for Recovery Audit Contractor (RAC), Supplemental Medical Review Contractor (SMRC), Quality Improvement Organizations (QIO), and internal medical review department by reviewing reason for denial against new/updated clinical documentation
  • Compose clear and concise denial letters for both providers and beneficiaries
  • As necessary: Rewrite IRF denial letter template, assist coworkers
  • Skills Used: Critical thinking, medical terminology, CPT/HCPCS books, MAS, OnBase, MS Office

RN – MEDICAID UTILIZATION MANAGEMENT

PacificSource Health Plans
03.2020 - 06.2021
  • Utilization Management for Medicaid prior authorizations and inpatient stays
  • Reviewing clinical documentation for determinations of preauthorizations for planned procedures, and inpatient hospitalizations, sub-acute/skilled care, outpatient care, hospice and home health for medical necessity
  • This is completed by utilizing Oregon Health Plan (OHP) Prioritized List of Health Services, Oregon Administrative Rules, & external review guidelines such as Milliman (MCG), Local Coverage Decisions (LCDs) and Optum360 Medical Reference Engine
  • Maintaining compliance with state standards
  • As necessary: Working on additional projects: team-building and resource matrix
  • Also had the ability to partner with local hospital to administer COVID-19 vaccines
  • Skills Used: Nursing assessment, critical thinking, organizational skills, multi-tasking, MS Office

RN – INTEGRATED CARE MANAGER

WPS Health Insurance
08.2016 - 01.2020
  • Utilization Management for three lines of commercial insurance
  • Adherence to member’s insurance policies/benefits & reviewing clinical documentation for determinations of medical necessity for preauthorizations for planned procedures, and inpatient hospitalizations, sub-acute/skilled care, outpatient care, hospice and home health for medical necessity
  • This is completed by utilizing internal medical policies & external review guidelines such as Milliman (MCG), Hayes and NCCN
  • Close collaboration with staff, physicians, medical directors, case management and other internal/external customers
  • Maintaining compliance with NCQA standards
  • As necessary: Working on quality & process improvement projects for workforce optimization within the department; Reviewing claims data & pricing for steerage of durable medical equipment
  • Skills Used: Nursing assessment, critical thinking, organizational skills, multi-tasking, MS Office, Aerial, OnBase, Facets

RN – COLLECTIONS SPECIALIST

American Red Cross
04.2014 - 08.2016
  • Obtain physical assessment by checking blood pressure, pulse, temperature & hemoglobin
  • Obtain & verify health history to maintain safety, quality & purity of blood products
  • Perform venipuncture according to Red Cross & FDA standards
  • Care for & assist donors who have adverse reactions
  • Skills Used: Venipuncture; Vitals; medical terminology

RN – HEALTH & WELLNESS DIRECTOR

Brookdale Senior Living
04.2012 - 05.2014
  • Manage day-to-day clinical operations of two assisted living communities to ensure residents healthcare needs are met
  • Collaborate with physicians, nurse practitioners, hospice providers, home health companies and therapy departments on resident status
  • Responsible for the direct supervision of care giving and coordination of health care needs
  • Provide training, supervision and monitoring of associates including medication administration
  • Perform assessments of potential residents in hospitals, rehab facilities & homes to determine if they are appropriate for community
  • On-call24 hours Monday-Friday for any staff questions, concerns or to report any resident incidents
  • Compile reports on nutrition/health status, resident incidents, and review data to make changes as appropriate
  • As necessary: Teach state approved CBRF medication course for new associates & evaluations of medication administration
  • Collaborate with the sales team to meet with potential residents & provide assessments in a timely manner
  • Complete & review various reports to look for trends/change in patient health status
  • Ensure individual service plans are up to date
  • Update third party providers and families of resident status
  • Conduct bi-weekly collaborative care review meetings with therapy department, director & lead associate
  • Attend regional team meetings & conduct monthly staff meetings
  • Perform medication competency evaluations of staff
  • Rotating weekend on-call
  • Monthly review of MAR from pharmacy for all medications for all residents
  • Skills Used: Nursing assessment, medication administration (oral, IM), educating RAs, teaching state approved medication administration course for CBRFs; MS Office

RN – TRIAGE: INTERNAL MEDICINE

Dean Clinic West
09.2008 - 04.2012
  • Include, but are not limited to telephone triage, performing patient education, care management, assessing patient’s physical and psychological needs, administering medications, assisting physicians with procedures, supervising and directing the actions of unlicensed staff, responding to medical emergencies and participates in education to the Family Medicine Residency Program and other trainees.Triage patient phone calls using critical assessment skills
  • Educate patients on lab results, medications, disease processes, dietary requirements and procedures as well as rule out any emergency situations
  • Initiating IV therapy, assisting with procedures and administering medications per MD request
  • Using Epic EMR to review prior MD appointment and telephone notes, send in-basket messages to MDs with patient questions and concerns, responding to patients via MyChart and sending letters to patients
  • As necessary cover for LPNs / MAs by rooming patients & performing physical assessments
  • Ensure crash cart is up to date by checking equipment & medications weekly
  • Instruct staff on appropriate waste segregation
  • Assist LPNs and MAs with complex patient medical histories and provide education when needed
  • Accomplishments: ACLS certification; fill-in PRN in Quality Improvement; work PRN in flu clinics
  • Skills Used: Nursing assessment; medication administration (oral, IM, SQ, IV); critical thinking; MS Office, Epic

LPN – MULTI-SPECIALTY FLOAT

Dean Clinic East
08.2007 - 09.2008
  • Working in various departments including Internal Medicine, Family Medicine, ENT, Urology, Podiatry and Pediatrics
  • Run practices for many physicians in various departments
  • Assisting with procedures, scheduling and educating patients, administering medications, triage phone calls, preparing charts, notifying patients of lab results and rooming patients for visits with MDs
  • Obtain reason for visit & pertinent medical history and vitals
  • Being a resource & educating new staff on department policy & physician preferences
  • Other duties as assigned
  • Skills Used: Medication administration (oral, IM, SQ), vitals; MS Office, Epic

LPN – CHARGE NURSE

Gray's Nursing Home
08.2005 - 07.2007
  • Supervise and delegate work to CNAs
  • Coordinate safe and effective care for20 residents
  • Duties including medication administration, tube feedings and head-to-toe assessments
  • Charting for MDS, Medicare and weekly assessments
  • Taking telephone doctor orders; ordering residents medications for the upcoming week; supervising CNAs; working as a team with the CNAs, RNs, dietary, housekeeping, maintenance and activities

STUDENT SERVICES

UW Law School
03.2001 - 05.2003
  • Set up complete Law School timetable & course/instructor information by using PeopleSoft
  • Access course data: add/drop/credit change
  • Assist students with special exam & classroom accommodations (ADA & ESL students)
  • Assist students in registering for courses & rescheduling exams
  • Enter courses into PeopleSoft
  • Assist with event planning: new student orientation & LEO banquet by making brochures, ordering food & selling tickets
  • Schedule room reservations
  • MS Office, People Soft

OFFICE ASSISTANT

Perry Judds
09.2000 - 03.2001
  • Enter UPS reports using Paradox, make copies & send to corporate office
  • Enter labor & materials tables using Excel & Paradox for billing
  • Answer multi-line phone & transfer calls or take messages
  • Order office supplies with purchase order obtained from corporate
  • Enter payroll into Ceridian
  • Print out time sheets & distribute
  • File courier billing
  • Assist graphic designers with marking proof pages

Education

Associate Degree In Nursing - Nursing

Southwest Wisconsin Technical College
Fennimore, WI
05.2008

Skills

  • Basic life support
  • Clinical judgment
  • Compassion and empathy
  • Discharge planning
  • Patient education and counseling
  • Patient management
  • Case management
  • Managing deadlines
  • Chronic disease management
  • Preventive health
  • Patient relations

Timeline

RN – UTILIZATION MANAGEMENT

Medasource/HNFS/TRICARE
05.2024 - Current

RN – MEDICARE APPEALS ANALYST

WPS Health Insurance
08.2021 - 05.2024

RN – MEDICAID UTILIZATION MANAGEMENT

PacificSource Health Plans
03.2020 - 06.2021

RN – INTEGRATED CARE MANAGER

WPS Health Insurance
08.2016 - 01.2020

RN – COLLECTIONS SPECIALIST

American Red Cross
04.2014 - 08.2016

RN – HEALTH & WELLNESS DIRECTOR

Brookdale Senior Living
04.2012 - 05.2014

RN – TRIAGE: INTERNAL MEDICINE

Dean Clinic West
09.2008 - 04.2012

LPN – MULTI-SPECIALTY FLOAT

Dean Clinic East
08.2007 - 09.2008

LPN – CHARGE NURSE

Gray's Nursing Home
08.2005 - 07.2007

STUDENT SERVICES

UW Law School
03.2001 - 05.2003

OFFICE ASSISTANT

Perry Judds
09.2000 - 03.2001

Associate Degree In Nursing - Nursing

Southwest Wisconsin Technical College

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NATALIE LUHMAN