Pamela M. Bowman
Cincinnati,Ohio
Summary
Seeking a role as a Registered Nurse, Quality Assurance Director, where my 16 years of Nursing, skilled in multiple areas of direct patient care, training, quality, auditing, documentation, leadership management, hospital, Insurance, education, and advocacy in the field of healthcare will be utilized.
Overview
10
10
years of professional experience
1
1
Certification
Work History
Registered Nurse, Director of Quality Assurance, Complex & Clinical Audit, Payment Integrity
Elevance Health
07.2023 - Current
- Ensures departmental objectives are achieved through the effective utilization of resources.
- Directs the evaluation of the quality of company compliance standards issued by corporate, customer agreements, Blue Cross Blue Shield Association, and various government agencies.
- Training, policy and process creation.
- Manages performance and compliance to determine the adequacy of the internal controls and identifies workflow efficiencies.
- Ensures deficiencies in compliance are identified and recommendations are prepared as necessary to strengthen the control environment.
- Completes special projects that are complex, confidential, and sensitive in nature.
- Develops and maintains positive and productive working relationships with internal associates and management and external contacts.
- Hires, trains, coaches, counsels, and evaluates performance of direct reports.
- Supports the education and growth of greater than 10 associates.
- Conducts annual evaluations, performance reviews and goal setting for associates.
- Manages departmental costs to ensure budget adherence.
Registered Nurse, Manager, Complex & Clinical Audit, Program Integrity
Elevance Health
10.2021 - 07.2023
- Manages Cost of Care savings for Department.
- Ensures Department meets savings and performance goals.
- Maintains relationships with Implant Providers.
- Establishes and implements new and revised auditing concepts, practices, and procedures.
- Defines audit scope and identifies new audit opportunities.
- Establishes Audit Goals for Team of Auditors.
- Ensures adherence to both goals and application of sound audit practices.
- Coaches, counsels, evaluates performance of direct reports.
Clinical Lab Adjunct Nursing Instructor
Xavier University
08.2022 - 04.2023
- Conducted undergraduate Nursing lab education and additional instruction when needed.
- Served as an adviser for students and evaluated student’s skills and lab coursework.
- Engaged in other activities which supported the student’s growth and development.
- Evaluated students at the end of their course for readiness for progression.
Registered Nurse, Nurse Auditor Lead
Anthem Blue Cross, Blue Shield
10.2019 - 10.2021
- Provide overall support to Manager and 2 Teams of Nurses.
- Team training, Claim System Testing and Training.
- Assist with complex claim Provider Audits including Implants, Readmissions and DRG Validation.
- Access and monitors weekly recovery reports.
- Provide feedback to auditors related to audits and special projects.
- Create Desk Top Procedures and Team Policies.
- SharePoint Administrator for Team SharePoint Site.
- Creator of Department Mentoring Program.
Registered Nurse, Quality Evaluator
Anthem Blue Cross, Blue Shield
11.2017 - 10.2019
- Built Provider audit program for Commercial lines of business.
- Performed Quality Audits to support a team of >30 associates, by evaluating completed Commercial Complex Audits.
- Educate and train new and existing associates on system navigation for claims verification.
- Create new department policies and guidelines.
- Create and manage department SharePoint site.
- Facilitate Quarterly Newsletters for team, with reminders and best practices.
Registered Nurse, Provider Auditor/Sr
Anthem Blue Cross, Blue Shield
04.2015 - 11.2017
- Initiate financial recoveries of overpayments and query development to enable identifying overpayments.
- Facilitate audit reviews along with discussions between Anthem Contracting, and Healthcare Facilities, and Provider Engagement.
- Analyze and apply contract language for reimbursement of medical services.
- Subject matter expert for Implants.
- Educate new associates and orient them to the department.
Education
MSN Ed. -
Western Governor’s University
01.2022
BSN -
Western Governor’s University
01.2020
Registered Nurse -
Beckfield College
01.2009
Skills
- Initiative-taking
- Autonomous
- Critical thinker
- Analytical
- Creative
- Optimistic
- Accountable
- Organized
- Collaborative
- Ambitious
- Client and Associate Advocate
- Client Outreach
- Provider/Patient Educator
- Commercial Contract Interpretation
- Excellent written and oral communication
- Ability to learn and teach complex topics
- Collaborate on complex projects
- Motivates people and process leader
- Ability to resolve conflict while maintaining professional relationships
- SharePoint site developer
- SharePoint site administrator
- Microsoft Office
- MS Excel
- MS PowerPoint
- MS Word
- MS TEAMS
- Visio
- Outlook
- Work Day
- Various types of scorecards
Certification
Registered Nurse, Ohio, Active, Unrestricted, RN.350055, 05/09
Skills
Initiative-taking, autonomous, critical thinker, analytical, creative, optimistic, accountable, organized, collaborative, ambitious, Client and Associate Advocate, Client Outreach, Provider/Patient Educator, Commercial Contract Interpretation, Excellent written and oral communication, Ability to learn and teach complex topics, Collaborate on complex projects, Motivates people and process leader, Ability to resolve conflict while maintaining professional relationships, SharePoint site developer and site administrator, Microsoft Office: Excel, PowerPoint, Word, MS TEAMS, Visio, Outlook, SharePoint 2010, 2013, Central Facets, FEP, WGS, NY Empire, Commercial claim systems, Workday, EPIC, WellPoint Content Framework, EPA, Various types of scorecards (Commercial Quality and Provider)
Timeline
Registered Nurse, Director of Quality Assurance, Complex & Clinical Audit, Payment Integrity
Elevance Health
07.2023 - Current
Clinical Lab Adjunct Nursing Instructor
Xavier University
08.2022 - 04.2023
Registered Nurse, Manager, Complex & Clinical Audit, Program Integrity
Elevance Health
10.2021 - 07.2023
Registered Nurse, Nurse Auditor Lead
Anthem Blue Cross, Blue Shield
10.2019 - 10.2021
Registered Nurse, Quality Evaluator
Anthem Blue Cross, Blue Shield
11.2017 - 10.2019
Registered Nurse, Provider Auditor/Sr
Anthem Blue Cross, Blue Shield
04.2015 - 11.2017
MSN Ed. -
Western Governor’s University
BSN -
Western Governor’s University
Registered Nurse -
Beckfield College