Nisha Matson
Ringwood,NJ
Overview
24
24
years of professional experience
Work History
AUDITING SPECIALIST
CODING ADVANTAGE LLC
04.2024 - Current
- Performs medical record reviews to determine compliance with regulations and standards instituted by the Ohio Administrative Code
- Conducts medical record review or compliance reviews for mental health treatment and submits preliminary findings/outcomes
- Review and monitor changes in clinical guidelines as applicable.
BEHAVIORAL HEALTH CLINICIAN I
HORIZON BLUE CROSS BLUE SHIELD
08.2023 - 02.2024
- Performed concurrent reviews for mental health and/or substance abuse inpatient care, residential and PHP/IOP utilizing MCG medical necessity or ASAM criteria for in network and out of network providers
- Evaluate the necessity and appropriateness of care
- Authorize and review utilization of mental health and substance abuse treatment
- Assist with discharge planning and ambulatory follow-up care
- Interact with Physician Advisors regarding unauthorized concurrent clinical cases for case resolution.
CLINICAL QUALITY CONSULTANT
OPTUM/UNITED health group
06.2015 - 11.2022
- Practice performance manager for Quality Field Operations in support of Medicare Advantage STARS program for designated provider groups
- Provide analytical interpretation of HEDIS measures including CAHPS/HOS reporting and monthly provider summaries during on-site and virtual meetings for value based contracting initiatives
- Develop solution-based strategies to support best practice success and work towards enhancing quality health screening standards and targeted physician incentive goals
- Initiate collaborative strategies with provider groups, optimize operations focusing on improved clinical reporting and operations, and coordinate onsite and remote clinical evaluations of medical records
- Provide education and communications for physicians and staff for provider practices
- Develop strategic action plans to support provider practices in continuous quality improvement using approved clinical practice guidelines, HEDIS, CMS, NCQA and other reporting tools.
Per Diem RN – PSYCHIATRIC EMERGENCY/Behavioral Health/Chemical Dependency
St. Clare’s Hospital
01.2010 - Current
- Coordinate patient care/crisis screenings using collaborative efforts with healthcare team in accordance with nursing process and practice for substance abuse, voluntary and involuntary inpatient units including legal aspects of crisis screenings
- Adhere to all state, hospital and regulatory procedures and policies
- Serve as acting charge nurse for licensed and unlicensed staff; coordinate workflow including all admission and discharge activity
- Complete insurance pre-authorizations for potential inpatient admissions
- Full utilization of hospital systems including Cerner and EPIC for nursing documentation.
Per Diem RN – ADULT PSYCHIATRY/Eating Disorder
barnabas health rOBERT WOOD JOHNSON UNIVERSITY HOSPITAL SOMERSET
01.2011 - 02.2021
- Coordinate and evaluate patient care using collaborative efforts with healthcare team in accordance with nursing process and standards of care and practice
- Nursing functions include complete assessments and treatment planning for new admissions, implement patient care and lead nursing education group
- Adhere to all hospital and regulatory procedures and policies
- Full utilization of Cerner Millennium and Allscripts for nursing documentation.
Senior Care manager
Magellan Health Services
09.2012 - 10.2013
- Perform concurrent reviews for mental health inpatient care utilizing medical necessity or ASAM criteria
- Authorize and review utilization of mental health and substance abuse treatment for inpatient and intermediate care
- Assist with discharge planning and ambulatory follow-up care
- Interact with Physician Advisors regarding unauthorized concurrent clinical cases for case resolution.
Staff RN – CHemical Dependency/ rehab
Summit Oaks Hospital
01.2009 - 11.2010
- Coordinate and evaluate patient care for medical detox using collaborative efforts with healthcare team members in accordance with nursing process
- Served as acting charge nurse.
Commodity Expert – Information Technology – Corporate Procurement
Metropolitan Life Insurance
12.2000 - 04.2009
- Collaborate with internal customers, technology management team, vendors, legal team and financial approvers for sourcing projects
- Liaison with internal contracting team throughout entire sourcing life cycle
- Negotiate with vendors on contract terms, service levels, pricing, corporate policies and contractual expectations; follow-up included vendor monitoring and audits.
Timeline
AUDITING SPECIALIST
CODING ADVANTAGE LLC
04.2024 - Current
BEHAVIORAL HEALTH CLINICIAN I
HORIZON BLUE CROSS BLUE SHIELD
08.2023 - 02.2024
CLINICAL QUALITY CONSULTANT
OPTUM/UNITED health group
06.2015 - 11.2022
Senior Care manager
Magellan Health Services
09.2012 - 10.2013
Per Diem RN – ADULT PSYCHIATRY/Eating Disorder
barnabas health rOBERT WOOD JOHNSON UNIVERSITY HOSPITAL SOMERSET
01.2011 - 02.2021
Per Diem RN – PSYCHIATRIC EMERGENCY/Behavioral Health/Chemical Dependency
St. Clare’s Hospital
01.2010 - Current
Staff RN – CHemical Dependency/ rehab
Summit Oaks Hospital
01.2009 - 11.2010
Commodity Expert – Information Technology – Corporate Procurement
Metropolitan Life Insurance
12.2000 - 04.2009
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