REBECCA EVERETT

• Streamlined Claims Processing: Reviewed live claims for medical necessity, pre-existing conditions, infertility services, and prior authorizations, exceeding monthly goals by 100%. This ensured accurate and efficient claim processing.
• Enhanced Care Coordination: Collaborated with physicians, case managers, and other healthcare professionals to resolve claim issues, prioritize inquiries, and reduce customer/provider frustration. Served as a liaison between departments, fostering seamless communication throughout the care journey.
• Boosted Efficiency and Compliance: Identified workflow inefficiencies, proposed SOP improvements, and organized workload for optimal department performance. Supported accreditation efforts by ensuring adherence to regulatory guidelines during reviews.
• Championed Process Improvement: Participated in performance improvement initiatives to streamline workflows across the organization, leading to increased productivity within departments.

• Boosted Team Performance: Increased team productivity through efficient workflow implementation and clear expectations. Developed staff skills with targeted training, leading to improved performance and career advancement opportunities.
• Enhanced Operational Efficiency: Streamlined operations for increased efficiency. Identified and addressed operational inefficiencies, leading to an overall 95% improvement in effectiveness. Championed continuous improvement efforts by promoting best practices and implementing corrective measures.
• Cultivated Positive and Productive Work Environment: Reduced employee turnover by fostering a positive work environment and providing ongoing feedback. Resolved conflicts promptly, maintaining a harmonious and productive team atmosphere.
• Improved Customer Satisfaction: Improved customer satisfaction with timely responses, addressing concerns effectively, and finding solutions. Cultivated strong relationships with key clients through consistent communication and excellent service delivery.
• Leadership and Collaboration: Led major departmental initiatives that drove innovation or addressed critical business challenges. Collaborated effectively with other departments to achieve organizational goals. Conducted performance evaluations, identifying areas for improvement and guiding professional development plans.

• Streamlined Claims Processing: Reviewed live claims for medical necessity, pre-existing conditions, infertility services, and prior authorizations, exceeding monthly goals by 100%. This ensured accurate and efficient claim processing.
• Enhanced Care Coordination: Collaborated with physicians, case managers, and other healthcare professionals to resolve claim issues, prioritize inquiries, and reduce customer/provider frustration. Served as a liaison between departments, fostering seamless communication throughout the care journey.
• Boosted Efficiency and Compliance: Identified workflow inefficiencies, proposed SOP improvements, and organized workload for optimal department performance. Supported accreditation efforts by ensuring adherence to regulatory guidelines during reviews.
• Championed Process Improvement: Participated in performance improvement initiatives to streamline workflows across the organization, leading to increased productivity within departments.

• High-Volume Reviewer: Efficiently managed daily caseload of 13-25, ensuring timely and accurate reviews.
• NICU Program Champion: Played key role in launching NICU program by requesting policy inclusion for newborns, reviewing admissions, tracking claims, and collaborating with membership and claims departments for seamless case creation and review.
• Benefits and Coverage Expertise: Demonstrated strong clinical knowledge by evaluating medical guidelines and benefit coverage to determine service appropriateness.
• Problem-solving Skills: Devised or identified solutions for irregular requests and issues, ensuring accurate claim processing.
• Cross-Trained and Flexible: Proactively filled in for colleagues by leveraging cross-training in medical claims review, demonstrating adaptability and a commitment to team support.
• Prior Authorization Proficiency: Conducted reviews for services requiring prior authorization, ensuring proper member coverage and efficient service delivery.

• Secured Authorizations: Efficiently secured authorizations from multiple insurance carriers for various care levels, ensuring seamless patient transitions.
• High-Volume Review with Clinical Expertise: Reviewed a high volume of patient charts, leveraging strong nursing knowledge and state guidelines to determine medical necessity.
• Coding Proficiency: Collaborated with insurance agents regarding ICD-10 and CPT codes, demonstrating expertise in medical coding.
• Complex Case Collaboration: Partnered with Medical Director to review clinically complex patients, ensuring appropriate care delivery.
• Cost-Containment Champion: Employed comprehensive utilization review strategies (prospective, concurrent, retrospective) to optimize resource allocation.
• NICU Revenue Code Expert: Served as subject matter expert in NICU revenue codes, ensuring accurate billing and reimbursement.
• Mentorship and Knowledge Sharing: Provided training and support to colleagues on OB and NICU cases, fostering a collaborative and knowledgeable team environment.

40 bed Level IIIb NICU unit.

• Advanced Care for Critically Ill Newborns: Delivered comprehensive, developmentally appropriate care to critically ill infants in a high-acuity Level IIIb NICU, utilizing advanced interventions like HFOV, INO, PICC lines, and chest tubes.
• Family-Centered Champion: Provided compassionate support and education to families, fostering trust and collaboration through open communication.
• Collaborative Care Coordination: Ensured seamless communication with physicians, implementing orders, interpreting test results, and jointly planning care with families and the medical team.
• Leadership and Mentorship: Led key initiatives including:Infection Control Champion: Reduced CLABSI rates through evidence-based practice implementation and educational programs.
  Mentor Program Co-creator and Co-chair: Established a program for new staff, providing confidential support and fostering professional growth.
  Unit Practice Committee Member: Advanced best practices through ongoing review and implementation.
  Extremely Low Gestational Age Newborn Team Member: Contributed to research aimed at improving outcomes for ELGAN infants.
  Clinical Instructor and Preceptor: Educated and mentored future nurses, fostering a strong pipeline of talent.
  Leadership Team Member: Collaborated on unit-wide quality improvement initiatives, including staff recruitment, retention, and communication.

• Patient-Centered Caregiver: Delivered comprehensive daily care to patients, including bathing, ambulation, feeding assistance, toileting, IV removal, and blood glucose monitoring, ensuring their comfort and well-being.
• Relationship Builder: Fostered trusting and caring relationships with patients and families, creating a supportive and compassionate healing environment.
• Clinical Vigilance: Proactively identified patients with declining health conditions and promptly notified the STAT Team, ensuring timely intervention and potentially life-saving measures.

• Client Advocate: Resolved a wide range of customer inquiries for credit card and student loan clients, including billing disputes, credit line increases, and account management.
• Collections Specialist: Handled both inbound and outbound collections calls, recovering delinquent student loan debt while maintaining professionalism and de-escalating frustrated customers.
• Coaching and Development: Mentored new hires and existing associates, ensuring efficient onboarding and successful performance.
• Results-Oriented: Consistently achieved goals, earning recognition through multiple Citi Star Awards, 3x Citi Quality Excellence Awards, and Student Loans Employee of the Month.

• Graduated Summa Cum Laude
• President's List all 4 semesters
• Active Member: Saint Luke's College Honor Society & SLSNA Community Committee
• Saint Luke's SAINT Award Recipient