Penny Crumbley
McDonough,GA
Summary
Experienced, results and detail oriented healthcare professional with extensive experience in managed care, EMR usage, regulatory compliance, quality, and utilization/case management. Knowledgeable of Commercial and Medicare payor coverage and regulations. Excellent interpersonal, organizational, and leadership skills. Specialties and areas of expertise include: Utilization Management and Care/Case Management Quality Assurance
Overview
25
25
years of professional experience
1
1
Certification
Work History
Clinical Documentation Specialist
Wellstar Healthcare System
10.2022 - 02.2023
- Questioned physicians regarding missing or unclear health record documentation and requested further information for clarification purposes.
- Maintained strong knowledge of medical terminology, diseases and conditions and procedures.
- Communicated with physicians, nurses and other caregivers to explain importance of accurate and clear documentation.
- Managed electronic clinical documentation and uploaded changes or updates using [Software].
- Carefully reviewed patient files for clarity on diseases, diagnoses and procedures to determine quality of care.
- Maintained accuracy, completeness and security for medical records and health information.
- Input data into computer programs and filing systems.
- Used correct diagnosis-related groups based on patient encounter details.
Registered Nurse, Utilization Management
WellStar Health System, Atlanta Medical Center
06.2019 - 10.2022
- Collaborated with physicians to establish appropriate admission status.
- Performed utilization review at various points throughout hospitalization.
- Discussed with physician documentation needed to decrease likelihood of denial.
- Using evidence-based criteria, provided reviews for up to 40 cases on a daily basis.
- Collaborated with physicians to complete Peer to Peer disputes for denials.
- Collaborated with various other departments such as Physician Advisors, Case Management, Patient Access Services, Appeals, and Risk Management.
- Updated charts throughout shifts with current, accurate information to maintain strict recordkeeping standards.
Registered Nurse, Quality Resource Management
Kaiser Permanente
03.2006 - 06.2019
- Performed utilization review and discharge planning responsibility for members admitted to non-core facilities including those who are admitted out of state.
- Coordinated discharge planning needs of members.
- Coordinated care with various other Kaiser departments such as transitions and case management, pharmacists for anti-coagulation monitoring, peer review, risk management, benefit administration, etc.
- Functioned as union member labor co-lead with job responsibilities to organize meetings, prepare agenda, and facilitate process improvement projects.
- Trained new employees and contract workers.
- Performed Target Review for prior authorizations of procedures, medications, and Durable Medical Equipment.
Registered Nurse, Case Manager
Piedmont Rockdale Medical Center
10.2000 - 03.2006
- Managed patient load of 20-40 patients.
- Performed both utilization review and discharge planning responsibilities for each patient
- Performed utilization review and case management for various types of insurance programs.
- Collaborated with physicians to assign appropriate admission status.
Registered Nurse, Utilization Review Specialist
Intracorp
08.1998 - 10.2000
- Performed utilization review, telephonic advice nursing, and case management for various types of insurance programs.
- Acted as telephone resource manager to monitor and manage call center.
- Received HIAA certificate in Fundamentals of Health Insurance Part A.
Education
Diploma - Registered
Georgia Baptist School of Nursing
Atlanta, GA03.1983
Skills
- Determination of Medical Necessity
- HIPAA Compliance
- Accurate Documentation
- Use of evidence-based criteria, MCG Criteria
- Physician Consultations
- Obtaining Authorizations
- Utilization Management
- Discharge Planning
- Collaboration with other departments
- Case management
Certification
ACDIS CDI Apprenticeship - received on 1/23/2023
Timeline
Clinical Documentation Specialist
Wellstar Healthcare System
10.2022 - 02.2023
Registered Nurse, Utilization Management
WellStar Health System, Atlanta Medical Center
06.2019 - 10.2022
Registered Nurse, Quality Resource Management
Kaiser Permanente
03.2006 - 06.2019
Registered Nurse, Case Manager
Piedmont Rockdale Medical Center
10.2000 - 03.2006
Registered Nurse, Utilization Review Specialist
Intracorp
08.1998 - 10.2000
Diploma - Registered
Georgia Baptist School of Nursing
Similar Profiles
Jeanette M CrawfordJeanette M Crawford
National Certified Medical Assistant at Wellstar Healthcare SystemNational Certified Medical Assistant at Wellstar Healthcare System
Cydrisse DooleyCydrisse Dooley
Phlebotomist at Wellstar Healthcare SystemPhlebotomist at Wellstar Healthcare System
Aisha HannerAisha Hanner
Patient Access Team Lead at Wellstar Healthcare SystemPatient Access Team Lead at Wellstar Healthcare System
Cheyenne DarceyCheyenne Darcey
Emergency Room Technician at Wellstar Healthcare SystemEmergency Room Technician at Wellstar Healthcare System
Daniel CharlieDaniel Charlie
Equipment Operator at Kellogg Brown & Root (KBR)Equipment Operator at Kellogg Brown & Root (KBR)