Nicole Spicer

• Manage general office procedures regarding scheduling, staffing, payroll, and general phone inquiries about DME services and cost.
• Conduct regular audits of medical records to ensure accuracy and completeness of documentation.
• Create and maintain office policies and procedures to ensure smooth operations and compliance with multi-state regulations and accreditation of licenses.
• Resolve disputes between vendors providing services or products to the practice in a timely manner.
• Coordinate with insurance companies to verify coverage and authorizations of services rendered.
• Maintain accurate patient data, including medical history, charting requirements, demographics and other relevant documents needed for claim submission.
• Supervise patient billing, collections, ABN completion, financial education on copays and coinsurance cost, and assist with cash posting.
• Completed RAC audits and submitted reconsiderations for CMS reviews.

• Analyzed financial information related to insurance coverage eligibility prior to initiating/referring for services.
• Identified high-risk cases requiring monitoring or specialized discharge interventions.
• Actively participated in daily multidisciplinary meetings to discuss complex cases to promote optimal patient outcomes.
• Reviewed clinical data, including lab results, radiology reports, and vital signs, to assess the appropriateness of treatments and level of care statuses.
• Facilitated transitions between levels of care through effective coordination of resources within the available care choices.
• Completed insurance verifications and verified accuracy of demographics collected.
• Communicated regularly with family members regarding patient care needs and progress toward goals.
• Ensured compliance with regulatory standards concerning utilization review, ethical decision making, and legal aspects of case management practice in close conjunction with risk management.
• Participated in monthly budget meetings to review DRG outcomes and length of stay times.
• Advocated for patient needs with interdisciplinary team and insurance reviewers.

• Maintained detailed documentation of all utilization review activities according to applicable standards.
• Collaborated with physicians, additional case managers, and other healthcare professionals to ensure appropriate utilization of services and levels of care.
• Participated in interdisciplinary team meetings to discuss complex cases requiring authorization for specialized services or equipment.
• Educated providers on current evidenced based clinical guidelines, best practices measures, and regulatory requirements, as well as reviewed cases for adherence to policy criteria.
• Prepared written summaries detailing continued stay needs and/or file appeal request.
• Referred cases to secondary review for failure to meet admission or continued stay criteria.
• Documented all utilization review activities, findings, and decisions in patient records and databases.
• Collaborated with case managers to facilitate timely discharge planning and transition of care.

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• See previously listed job duties at Clark Regional Medical Center
• Completed quick utilization chart reviews to determine the initial status of criteria for placement from direct and ER admissions.