Priscilla Hover

Nurse Auditor 2021 to Present-

Validates and interprets medical documentation to ensure capture of all relevant coding. Identifies members with high risk CMS Hierarchical Condition Categories (HCC) and refers cases for annual follow-up care by disease management, case management, and primary care providers as appropriate for assessment/intervention. Identifies the root cause analysis of audit findings and submits recommendations for appropriate change management. Applies clinical and coding experience to conduct reviews of provider codes and billing. Makes decisions regarding own work methods, occasionally in ambiguous situations, and requires minimal direction and receives guidance where needed. Follows established guidelines/procedures.

Utilization Review Nurse 2019 to 2021

managed initial inpatient reviews for Humana Medicare members; managed member with concurrent reviews, case management, and discharge planning for Humana Medicaid.

Conducted initial, concurrent, retrospective reviews for clients and their contract/ facility protocol. Demanded flexibility to clients needs at time of shift. In addition to UM, job tasks included chart auditing and appeal letter during downtime. Required to work with EHR: EPIC, Cerner, Meditech, Midas, Sorien.

Experience in ICU 3yrs, Emergency Room 2yrs, Mother-Baby 2.5yrs, Cardiac Interventional Unit with telemetry 4 yrs, Utilization Review 4.5yrs