Patricia N. Tilley
Fuquay,N.C.
Summary
Organized and dependable professional skilled in managing multiple priorities while maintaining a positive attitude. Strong willingness to embrace additional responsibilities to achieve team objectives. Expertise in determining benefit eligibility and appropriate reimbursement allowances for complex claims and products, leveraging clinical experience, medical literature, and comprehensive knowledge of medical policies. Proficient in navigating complex computer application software systems to ensure accurate and efficient processing of claims.
Overview
29
29
years of professional experience
1
1
Certification
Work History
Senior Medical Review Analyst
Blue Cross Blue Shield
01.2020 - Current
- Recognizes, documents, and reports inappropriate billing of institutional Host claims. Identifies situations in which claims filing/coding guidelines are not being followed by providers utilizing The Provider Blue Book and appropriate Reimbursement Policies.
- Documents claims savings with appropriate denial language in the HDPR savings database for each reviewed claim. Identifies duplicate Host facility claims within Facets to facilitate efficient adjudication of claims.
- Ensures that review and determinations meet all requirements per line of business by Regulatory and Accrediting bodies.
- Determines, medical necessity, benefit eligibility and/or appropriate reimbursement allowances for complex claims and/or products by using clinical experience, medical literature, medical records, certificate guidelines, medical policy and several complex and varied computer application software systems.
- Ensures that review and determinations meet all requirements per line of business by Regulatory and Accrediting bodies.
- Identifies, documents, and escalates systems and process problems. Through analysis, determines root cause and recommends possible solutions. Defines, communicates and follows up as appropriate on the root causes of errors to others.
- Maintains confidentiality of all PHI in compliance with state and federal laws.
- Communicates with members and providers to obtain additional information. Informs members, providers, and internal customers of claims status and determinations. Documents the required clinical information, source and rationale (referencing the appropriate internal and external resources) for decision-making in the appropriate medical management tools.
- HDPR Review: High Dollar Pre-Payment Review
Registered Nurse Clinician
Prospect Blue
03.2020 - 09.2020
- Provide respiratory and temperature screening in a business environment for essential personnel at Wells Fargo, Fidelity Investments and United Therapeutics on behalf of Affiliated Physicians.
Senior Coding Analyst
Blue Cross Blue Shield
03.2017 - 10.2018
- Provide consultative expertise to other areas regarding current and emerging coding/documentation issues.
- Obtain and maintain all Clinical Code sets as issued from CMS, AMA and ADA.
- Collaborate with multiple business areas to determine & ensure proper coding logic in the claims processing systems, based on member benefits & existing guidelines.
- Acts as a knowledge resource to pricing & expense analyst regarding charge/pricing related issues, providing processing and programming recommendation.
- Identify trends in coding practices to internal/external audiences and make recommendations regarding coding standards.
- Gather appropriate claims data, analyze and prepare summary of analysis to assist in the development of resource allocation strategies to meet changing business needs.
- Respond to internal and external inquiries regarding specific medical procedure coding issues and provide education on proper coding techniques via written and/or telephonic communications.
- Develop educational materials for providers identified as outliers and collaborate with Network Management on delivery/communication of information to provider.
- Maintain documents for tracking audit results, status/outcomes of reviews etc.
- Participate in or lead special projects based on business area needs requiring independent, sound decision making and broad-based understanding of impact on the individual department as well as impact on corporate objectives.
- Work from home
Senior Medical Review Analyst
Blue Cross Blue Shield
03.2007 - 03.2017
- Review medical records, claim data, and medication history to for tier of coverage determination.
- Review claim data, medication history, and medical records in conjunction with BCBCNC corporate medical policy to determine medical necessity.
- Price surgical, drug, and durable medical equipment claims using corporate policy along with current pricing guidelines and appropriate coding guidelines.
- Review claims with high-dollar threshold of $35k or greater for correct claim processing, along with reviewing for clinical appropriateness using claim data, available medical records, and medication history.
- Review claim data and clinical history to determine inappropriate medical spending to create cost-saving medical reviews within the Medical Review department and facilitate claim process improvements.
- Review providers within the BCBS network for correct coding and medical necessity of services provided as supported by medical records.
- Provide support to UNC/Rex customer within the medical review department to review claims for faster processing, accuracy of payments, resolution of claim payment.
- Work from home
- Risk Review: Review medical records, claim data, and medication history to for tier of coverage determination.
- Medical Necessity: Review claim data, medication history, and medical records in conjunction with BCBCNC corporate medical policy to determine medical necessity.
- Pricing: Price surgical, drug, and durable medical equipment claims using corporate policy along with current pricing guidelines and appropriate coding guidelines.
- High-Dollar Review: Review claims with high-dollar threshold of $35k or greater for correct claim processing, along with reviewing for clinical appropriateness using claim data, available medical records, and medication history.
- Data Mining: Review claim data and clinical history to determine inappropriate medical spending to create cost-saving medical reviews within the Medical Review department and facilitate claim process improvements.
- Special Investigation Review: Review providers within the BCBS network for correct coding and medical necessity of services provided as supported by medical records.
- Onsite UNC/Rex Healthcare RN: Provide support to UNC/Rex customer within the medical review department to review claims for faster processing, accuracy of payments, resolution of claim payment.
Staff Nurse
Hudson Valley Dermatology
01.1997 - 07.2007
- CO2 laser procedures.
- Glycolic and TCA peels.
- Sclerotherapy.
- Cryosurgery.
- Botox.
- D & C.
- Assisted: CO2 laser procedures.
- Glycolic and TCA peels.
- Sclerotherapy.
- Cryosurgery.
- Botox.
- D & C.
- Performed: Local anesthesia.
- Allergy patch tests.
- Fungal cultures.
- Intramuscular and subcutaneous injections.
- Nail debridements.
- PUVA and photochemotherapy.
- Suture removal.
- Skin cancer exams.
- Venipuncture.
- Patient education.
- Telephone triage.
Surgical Nurse
Hudson Valley Dermatology
01.1997 - 07.2007
- Moh’s surgery.
- Skin grafts.
- Wedge resections.
- Advancements flaps.
- Blepharoplasty.
- Simple, intermediate, and complex repairs.
- Assisted with: Moh’s surgery.
- Skin grafts.
- Wedge resections.
- Advancements flaps.
- Blepharoplasty.
- Simple, intermediate, and complex repairs.
- Responsible for: Setting up sterile fields and surgical trays.
- Pre- and postoperative education.
- Dressing changes for the elderly.
- Postoperative daily wound checks.
Home Health Nurse
Buies Creek
07.2005 - 03.2007
- Provide direct patient care in a home setting for geriatric patient.
- Daily physical assessments.
- Medication administration.
- Daily update of patient status to family members.
- Developed and implemented appropriate nursing diagnoses.
- Evaluated client outcomes.
- Private Duty RN: Provide direct patient care in a home setting for geriatric patient.
- Daily physical assessments.
- Medication administration.
- Daily update of patient status to family members.
- Developed and implemented appropriate nursing diagnoses.
- Evaluated client outcomes.
OR Staff Nurse
Rex Hospital
01.2004 - 07.2005
- Verified patient consent.
- Documented patient care and sterile supply charges.
- Implemented and updated surgeons’ preference lists.
- Used and maintained OR equipment.
- Set up and maintained sterile field.
- Provided appropriate instrumentation.
- Circulating RN: Verified patient consent.
- Documented patient care and sterile supply charges.
- Implemented and updated surgeons’ preference lists.
- Used and maintained OR equipment.
- Scrub RN: Set up and maintained sterile field.
- Provided appropriate instrumentation.
- Surgical Environments: ENT
- GYN
- Pediatric
- General Surgery: Minor Ortho
- Neuro
Lead Medical Office Nurse
WakeMed
12.2002 - 07.2003
- Procurement of new equipment and sterile supplies.
- Organization of exam room equipment and stock.
- Established daily nursing protocol.
- Patient interviews and initial assessment.
- Telephone triage.
- Patient flow physical assessments.
- Instrument care and maintenance.
- Supervision of clinical secretary.
- Scheduling of patient diagnostic testing and surgeries.
- Patient pre-op instruction and education.
- New Office Set Up: Procurement of new equipment and sterile supplies.
- Organization of exam room equipment and stock.
- Established daily nursing protocol.
- Responsible for: Patient interviews and initial assessment.
- Telephone triage.
- Patient flow physical assessments.
- Instrument care and maintenance.
- Supervision of clinical secretary.
- Scheduling of patient diagnostic testing and surgeries.
- Patient pre-op instruction and education.
OR Staff Nurse
WakeMed
12.1999 - 12.2002
- Verified patient consent.
- Documented patient care and sterile supply charges.
- Implemented and updated surgeons’ preference lists.
- Used and maintained OR equipment.
- Set up and maintained sterile field.
- Provided appropriate instrumentation.
- Circulating RN: Verified patient consent.
- Documented patient care and sterile supply charges.
- Implemented and updated surgeons’ preference lists.
- Used and maintained OR equipment.
- Scrub RN: Set up and maintained sterile field.
- Provided appropriate instrumentation.
- Surgical Environments: ENT
- GYN
- Pediatric
- General Surgery: Minor Ortho
Staff Nurse
WakeMed
03.1998 - 11.1998
- Venipuncture.
- Administration of IV, IM, and PO Medications.
- Physical assessments.
- Medical-surgical tasks.
- Performed: Venipuncture.
- Administration of IV, IM, and PO Medications.
- Physical assessments.
- Medical-surgical tasks.
- Implemented: Appropriate nursing diagnoses and patient care.
- Evaluated: Client outcomes.
Education
Associate Degree of Nursing -
Wake Technical Community College
11.1996
Skills
- HIPAA regulations
- Medical coding
- Conflict resolution techniques
- Medical billing
- Medical record review
- Clinical data analysis
- Certified professional coder (CPC)
Accomplishments
Collaborated with team of 20 in the development of AI processing of medical invoices to facilitate faster review of complex itemized bills.
Subject Matter Expert of AI Bot for invoice review and processing.
Promoted to Senior Medical Analyst 2025
Maintains 100% audit quality.
Maintains 97% or greater production.
Certification
- RN: North Carolina, January 1997
- RN: New York State, September 1997
- Nurses’ Aide, March 1993
- CPC: January 2019
Timeline
Registered Nurse Clinician
Prospect Blue
03.2020 - 09.2020
Senior Medical Review Analyst
Blue Cross Blue Shield
01.2020 - Current
Senior Coding Analyst
Blue Cross Blue Shield
03.2017 - 10.2018
Senior Medical Review Analyst
Blue Cross Blue Shield
03.2007 - 03.2017
Home Health Nurse
Buies Creek
07.2005 - 03.2007
OR Staff Nurse
Rex Hospital
01.2004 - 07.2005
Lead Medical Office Nurse
WakeMed
12.2002 - 07.2003
OR Staff Nurse
WakeMed
12.1999 - 12.2002
Staff Nurse
WakeMed
03.1998 - 11.1998
Staff Nurse
Hudson Valley Dermatology
01.1997 - 07.2007
Surgical Nurse
Hudson Valley Dermatology
01.1997 - 07.2007
Associate Degree of Nursing -
Wake Technical Community College
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