RACHAEL RAPOLAS RN BSN CHCQM
Matawan,New Jersey
Summary
Enthusiastic registered nurse reviewer eager to contribute to team success through hard work, attention to detail and excellent organizational skills. Clear understanding of determining appropriate care and services and training in utilization review. Motivated to learn, grow and excel in nursing informatics.
Overview
12
12
years of professional experience
1
1
Certification
Work History
Nurse Reviewer
AIS, ISG
Iselin, NJ To Boston, MA
07.2014 - Current
- Reviews car accident PIP claims for nation/New Jersey for major car insurance companies for causality, medical necessity, duration, subsequent care, and fraud within state regulations
- When applicable, utilize Interqual guidelines for utilization review
- Creates physician review retrospective and pre-cert templates to review for necessity, relation, duration, subsequent care of treatment
- Reviews independent medical exam information, demographics, ICD9&10/CPT codes, and basic billing information for accuracy
- Previously trained and oriented new and current employees with the above duties in person and teleconference/Webex application.
Nurse Reviewer
Permedion: An HMS Company
East Windsor, NJ
02.2013 - 07.2014
- Reviewed retro and concurrent hospital medical records and bills for medical necessity, inpatient admission status, readmission status, quality, billing, and coding for Medicaid payment per Milliman/MCG guidelines
- Reviewed for complete components of medical record including clinical documentation, Medicaid information, and UB04 billing statement
- Reviewed prepay concurrent medical records within 72 hours
- Referred medical records for physician review if determined not substantiated
- Finalized physician reviews and appeal reviews by composing letters of outcomes and recommendations
- Reviewed FD999 claim adjustments for UR/Bill Audit prior to submission to Medicaid
- Review FD999 physician claim adjustments prior to Medicaid submission
- Created template and orient other nurse reviewers on FD999 reviews
- Performed FD999 bill audits
- Medical bill data entry, revenue code assignments, and audits of UB04 and itemized bills for outlier cases
- Constructed letter templates for Nurse Reviewers for all outgoing letters post physician review
- Tested developing software and provided feedback and recommendations to IT.
Telephonic Nurse Case Manager
Procura Management Inc, A Healthcare Solutions
Cranford, NJ
04.2012 - 10.2012
- Medically managed, utilizations reviewed, and positioned as middle liaison for approximately 330 car accident PIP claims for third party medical vendor for national car insurance
- Reviewed submitted treatment plans from medical providers for state-mandated requirements for precertification within 72 hours
- Interpreted medical and legal documentation for causality, symptomology, and medical necessity
- Coordinated diagnostics, treatments, durable medical equipment, medications, home services, transportation, and procedures/surgeries with other departments, vendors, medical offices, and facilities
- Initiated medical director reviews and independent medical exams per discretion
- Finalized outcomes of medical director reviews and independent medical exams
- Assessed and initiated special investigation referrals for fraudulent claims
- Initiated and coordinated interviews and treatment for catastrophic claims.
Home Care Nurse Case Manager/POD Leader
VNA Health Group
Newark, NJ
02.2012 - 04.2012
- Provided skilled nursing home care and multidisciplinary coordination in Essex County, NJ as full-time nurse case manager
- Reconciled medications by identifying side effects, interactions, and promoting optimum therapeutic effect
- Gathered contact information to improve continuity of care
- Provided skilled nursing care- provide wound care, draw blood for lab studies, supervise visits of home health aide, administer medications, provide relevant education, provide and research for mental health counseling, and provide advocacy
- As POD Leader, coordinated visits and care with per diem nurses in designated areas of coverage.
Field Assessment Nurse Reviewer
Visiting Nurses Association Health Group North
Newark, NJ
09.2011 - 04.2012
- Part of a newly created visiting assessment nurse team for Medicaid/Medicare programs
- Reviewed assessment forms from Medicare/Medicaid programs under third party health insurance carrier via Microsoft forms and email
- Communicated with assessment nurses for clarifying of documentation, identifying corrections, and stimulating critical thinking with questions and examples to assist in proper documentation
- Communicated with supervisor to constructively plan remediation of nurse assessors with consistent need of corrections or assistance.
Nurse Medical Case Manager
Newark, NJ
11.2011 - 02.2012
- Utilized nursing skills as a medical social worker
- Monitored and assisted with community resources with patients with AIDS/HIV, disabilities, elderly, traumatic brain injury, and chronic debilitating diseases
- Assisted patients by navigating Medicare/Medicaid and HMOs for utilizing benefits for medications, medical equipment, home health aide, speech/physical/occupational therapies, medical transportation, and nonmedical resources including financial assistance, food programs
- Calculated monthly budgets for patients of all services and equipment
- Advocates as patient representative to New Jersey’s Department Health & Senior Services and Division of Disability Services
- Collaborates with NJ Dept
- Health & Senior Services and Division of Disability Services for special requests such as respite care, equipment, and home health aide services
- Communicated with family members, caregivers, assisted living staff, home health aides & agencies, Lifealert System, day program centers, rehab facilities, doctors, and other healthcare providers to maintain continuum care through patient events.
Field Assessment Nurse
VNA Health Group
North Brunswick, NJ
06.2011 - 11.2011
- Scheduled and conducted initial assessments for members covered by Medicare/Medicaid programs under a third party health insurance carrier
- Interviewed with members, members’ caregivers/family and healthcare staff
- Completed assessment forms created by the insurance carrier and state of New Jersey
- Analyzed services/care in place and make recommendations for changes and/or continuation of care
- Addressed concerns or issues noted by receiving case manager
- Provided orientation and training to new hire assessment nurses
- Provided feedback on program’s progress and participate in and assist with preparing assessment nurse team meetings
- Reviewed peer nurses’ assessment forms and provided feedback.
Substitute School Nurse
David Brearley Middle/High School & Harding School
Kenilworth, NJ
12.2010 - 06.2011
- Held position at middle/high school which holds 670 students of thirteen to eighteen year olds as well as adult staff
- Triaged students and faculty
- Coordinated care with parents, staff, teachers, and aides regarding students.
Camp Nurse
Ramapo Country Day Camp
Airmont, NY
06.2010 - 08.2010
- Maintained safety and wellness at a summer camp for three year olds to twelve year olds as well as adult staff.
Education
Master’s Degree - Nursing Informatics
Thomas Edison State University
Bachelor’s Degree - Science of Nursing
Felician University, Middle, NJHigh
2009
Degree - undefined
2003
Skills
- Microsoft Word Office, Microsoft Teams, Basic Internet, Outlook, Adobe, Oracle Applications, LotusNotes, Webex, ADP, Lotus Notes, Skype, VPN, Webex, Paycom, Social Media
- Verizon Galaxy Tablet, Pointcare Tablet Application, Google Products
- Remote/Work from home setting
Certification
- ABQAURP/CHCQM Certification and Membership.
- Coursera: Google Data Analytics Professional Certification course complete in Fall 2022.
Additional Information
- New Jersey State Registered Nursing License expires May 2024.
Accomplishments
- Oriented, trained, and recommended feedback for new hire employees in different positions and employers.
- Achieved productivity by completing reviews with accuracy and efficiency.
- Returned to graduate school in pursuit of a master's degree in nursing informatics.
- Maintaining 4.0 GPA and received multiple scholarships while employed.
Timeline
Nurse Reviewer
AIS, ISG
07.2014 - Current
Nurse Reviewer
Permedion: An HMS Company
02.2013 - 07.2014
Telephonic Nurse Case Manager
Procura Management Inc, A Healthcare Solutions
04.2012 - 10.2012
Home Care Nurse Case Manager/POD Leader
VNA Health Group
02.2012 - 04.2012
Nurse Medical Case Manager
11.2011 - 02.2012
Field Assessment Nurse Reviewer
Visiting Nurses Association Health Group North
09.2011 - 04.2012
Field Assessment Nurse
VNA Health Group
06.2011 - 11.2011
Substitute School Nurse
David Brearley Middle/High School & Harding School
12.2010 - 06.2011
Camp Nurse
Ramapo Country Day Camp
06.2010 - 08.2010
Master’s Degree - Nursing Informatics
Thomas Edison State University
Bachelor’s Degree - Science of Nursing
Felician University, Middle, NJHigh
Degree - undefined
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