Patty Heffner Henkel
Youngsville,NC
Summary
Hardworking Prior Authorization Specialist/UM Reviewer with successful background working closely with insurance company representatives to gain preapproval for procedures and testing. Partnership with Federal Government CMS to assure accuracy and compliance. Detail-oriented performer with more than 19 years of managing documentation. Considered team player with exemplary multitasking skills. Superior customer service skills.
Overview
21
21
years of professional experience
Work History
Medical Review Specialist III
Empower AI
07.2023 - Current
- Maintained accuracy, completeness and security for medical records and health information for CMS.
- Input secure data into computer programs and verify accurate outcome.
- Reviewed medical records for completeness for Medicare DME.
- Quality review of selected prior Medicare claims for accuracy and compliance to Medicare regulation.
- Secured medical records against loss or unauthorized access.
Medical Reimbursement Lead
The Palomino Group
04.2023 - 06.2023
- Processed billing calls and answered questions from patients and third-party carriers.
- Corrected, completed and processed claims for multiple payer codes.
- Processed online and paper appeal submissions and refund requests.
- Used data entry skills to accurately document and input statements.
- Developed rapport with clients and vendors to cultivate loyalty and satisfaction.
- Kept vendor files accurate and up-to-date to expedite payment processing.
Prior Authorization Specialist II
Humana
01.2023 - 04.2023
- Reached out to insurance carriers to obtain prior authorization for testing and procedures.
- Input all patient data regarding claims and prior authorizations into system accurately.
- Obtained and logged accurate patient insurance and demographic information for use by insurance providers and medical personnel.
- Tracked referral submission during facilitation of prior authorization issuance.
- Prepared and distributed denial letters, detailing reasons for denial and possible appeal measures.
- Maintained compliance with patient privacy and security regulations
Prior Authorization Specialist, Registered Nurse Consultant, Care Manager
Clearlink Partners,
03.2022 - 11.2022
- Utilization Management and Prior Authorization for Medicare/Medicaid members across wide spectrum of Heath care needs
- Able to manage 20 plus cases using Medicare Guidelines, LCD/MCG, and other policies
- In process of obtaining CA nursing license
- Nevada nursing license obtained
- Care Plan creation for DSNP (dual eligibility for Medicare and Medicaid) population (Consultant RN)
- Remediation of team Care Plans for accuracy and coaching (Consultant RN- leadership; chosen for special projects)
Episodic Care Manager; Prior Auth for Pre Surgical
Blue Cross Blue Shield Of NC
12.2020 - 02.2022
- Utilization review-Review clinical notes to see if member meets medical policy for surgical procedures in a certain time frame for prior authorization
- Actively manage 12+ cases daily to ensure state and federal compliance and time frames using corporate medical policy and Milliman Care Guidelines
- Work in coordination with Acute hospital based team to ensure cases are transferred to their lists in order for timely follow up
- Train for application and program changes in the work environment
- Computer/Microsoft Office expert
- Utilization Management / Prior Auth
- Health insurance industry experience
- Medical terminology experience
- Maintain current licensing and complete relevant CEU's for continued learning, /leadership qualified
Episodic Care Manager, Home Health, DME
Blue Cross and Blue Shield of North Carolina
05.2014 - 12.2020
- Discharge Services Prior Authorization, Actively review and complete cases for members in items such as home health care and
- Durable Medical Equipment in accordance with medical policy
- Maintain list of 15+ cases daily to ensure timeliness in compliance with state and federal standards
- Leadership/Point person to help other Team members and maintain entire list to keep cases in compliance
- Kept team leader aware of issues with cases
- Maintain active licensure and training pertinent to my role as discharge ECM.
Level II Appeals Analyst
Blue Cross and Blue Shield of North Carolina
07.2012 - 05.2014
- Work with members and providers in second level of appeal for denied claims or preauthorizations
- Collaborated with Medical Directors and external medical experts to resolve member or providers appeal items
- Educated members and/or providers regarding outcome of appeal case to facilitate positive relationships going forward
- Managed list of cases independently to hold Appeal hearings over the phone in a timely manner
- Able to work appeals and grievances
- Assisted State Health Plan as back up analyst when needed.
- Represented highest level of expertise required to respond to regulators and media inquiries.
- Followed department guidelines and tools to conduct reviews.
Operations Manager
Healthways, Inc
04.2011 - 07.2012
- Established positive and effective communication among my team and organization leadership, reducing miscommunications and missed deadlines.
- Identified and resolved unauthorized, unsafe or ineffective practices.
- Set, enforced and optimized internal policies to maintain responsiveness to demands.
- Devised processes to boost long-term business success and increase profit levels.
- Successfully led team of 15 nurses, my team had highest Gallop Poll team satisfaction score of 4.75/5.
- Payroll, coaching, employee time metrics, and HIPPA compliance monitoring.
RN Staff Nurse
WakeMed
06.2006 - 04.2011
- Pre procedure cardiac cath lab care and education for Cardiac patients
- Administered medications via oral, IV and intramuscular injections and monitored responses.
- Effectively prioritized assignments, executing care based on each patient's relative condition and delegating tasks to available personnel deliver safe and efficient care.
- Assessment, Heath history, medication history and IV
- Lab analysis for appropriate pre patient status
- Patient Care Coordinator role to make daily cath lab schedule flow smoothly
- Accommodate patients waiting for procedures that were delayed.
- Updated patient charts with data such as medications to keep records current and support accurate treatments.
- Trained new nurses in proper techniques, care standards, operational procedures and safety protocols.
- Worked within interdisciplinary health care team to develop, implement and make adjustments to patient care plans, individualizing strategies and methods to improve health and meet recovery goals.
Staff Nurse
Duke University Medical Center Cardio, Thoracic
06.2004 - 07.2006
- Care of cardio thoracic post op patients to include CABG, stents, transplant of heart/ lung, LVAD patients and lung surgery patients.
- Monitored patients' conditions and reported changes in physical presentation, appearance and behavior to discuss treatment with physicians.
- Performed various nursing interventions such as wound dressing, vital sign monitoring and specimen collection.
- Identified patient care requirements by establishing personal rapport with patients and families.
- Collected blood, tissue and other laboratory specimens and prepared for lab testing.
- Precepted student nurses and oriented new hires, providing guidance and mentorship when teaching on hospital policies, emergency procedures and nursing best practices.
Education
Bachelor's degree - Nursing
Chamberlain College of Nursing
Youngsville, NCAssociate Degree - Nursing
Vance Granville Community College
Henderson, NCSkills
- Organizational Skills
- Superior customer service
- Interdepartmental Functions Coordination
- Specialized Healthcare Referrals
- Medication Side Effect Knowledge
- Pulmonary Hypertension
- Disease Processes
- Clear Patient Communication
- Excellent time management Interpersonal skills
- Nursing
- Medical Records
- EMR Systems
- Medication Administration
- Vital Signs
- Epic
- Caregiving
- Crisis Intervention
- Patient Care
- HIPAA
- Critical Care Experience
- Teaching
- Conflict management
- Interviewing
- Hospital Experience
- ICD-10
- Insurance Verification
- Utilization Management
- Documentation review
- Anatomy Knowledge
- Medical Terminology
- Managed Care
- Management
- Utilization review
- Typing
- Windows
- Medical management
- Analysis skills
- NCQA standards
- Care plans
- Home care
- Supervising Experience
- SharePoint
- Nurse Management
- Computer networking
- Communication skills
- Discharge planning
- Acute care
- Medical documentation
- Time management
- Data collection
- Leadership
- Computer skills
- Microsoft Office
- Case Management
- Registered Nurse (RN)-June 2004
- Compact State Nurse License
- Nevada State Nursing License
- California State Nursing License
- CDIS-Working on Clinical Documentation Information Specialist certification
- Assessments
- Work style: Conscientiousness — Highly Proficient
- Tendency to be well-organized, rule-abiding, and hard-working
- Full results: Highly Proficient
- Development in any professional field
- Employee Recruitment and Hiring
- Motivational Interviewing
Additional Information
- Compact Registered Nurse license; Nevada nursing license; California nursing license.
- Authorized to work in the US for any employer
Timeline
Medical Review Specialist III
Empower AI
07.2023 - Current
Medical Reimbursement Lead
The Palomino Group
04.2023 - 06.2023
Prior Authorization Specialist II
Humana
01.2023 - 04.2023
Prior Authorization Specialist, Registered Nurse Consultant, Care Manager
Clearlink Partners,
03.2022 - 11.2022
Episodic Care Manager; Prior Auth for Pre Surgical
Blue Cross Blue Shield Of NC
12.2020 - 02.2022
Episodic Care Manager, Home Health, DME
Blue Cross and Blue Shield of North Carolina
05.2014 - 12.2020
Level II Appeals Analyst
Blue Cross and Blue Shield of North Carolina
07.2012 - 05.2014
Operations Manager
Healthways, Inc
04.2011 - 07.2012
RN Staff Nurse
WakeMed
06.2006 - 04.2011
Staff Nurse
Duke University Medical Center Cardio, Thoracic
06.2004 - 07.2006
Bachelor's degree - Nursing
Chamberlain College of Nursing
Associate Degree - Nursing
Vance Granville Community College
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