REBECCA EVERETT

• (Returned to this role after serving as Medical Claims Review Supervisor.)
• Conducted comprehensive reviews of Commercial and Medicare Advantage claims, ensuring medical necessity, verifying pre-existing conditions, and processing prior authorizations.
• Exceeded monthly claim review goals by 100%, consistently improving efficiency and accuracy.
• Collaborated with interdisciplinary teams to resolve complex claims and authorization issues.
• Identified and implemented workflow improvements, including developing and updating Standard Operating Procedures (SOPs).
• Provided expert guidance on claims-related inquiries to internal departments.
• Prioritized claim processing to minimize customer and provider abrasion.
• Ensured compliance with regulatory guidelines during clinical review activities.
• Optimized workload organization to consistently meet deadlines and maximize departmental efficiency.
• Contributed to performance improvement initiatives aimed at streamlining organizational workflows.
• Served as a liaison, facilitating seamless communication and care coordination across departments.

• Increased team productivity by 20% within six months through streamlined workflows and clear performance expectations.
• Enhanced operational efficiency through regular process reviews and strategic implementation of changes.
• Reduced employee turnover by 15% through fostering a positive work environment and implementing a structured feedback and development program.
• Improved customer satisfaction ratings by 10% through timely inquiry resolution and proactive problem-solving.
• Developed and delivered targeted training programs, resulting in a 25% improvement in staff performance metrics.
• Facilitated cross-departmental collaboration to achieve organizational objectives.
• Conducted performance evaluations, providing constructive feedback and guiding professional development plans.
• Resolved team conflicts promptly, fostering a productive and harmonious work environment.
• Established and tracked key performance indicators (KPIs), driving continuous process improvement and team accountability.
• Enhanced team communication through regular meetings and open dialogue.
• Implemented corrective measures to address operational inefficiencies, resulting in increased overall effectiveness.
• Cultivated strong client relationships through consistent communication and exceptional service delivery.
• Led key departmental initiatives that drove innovation and addressed critical business challenges.
• Championed continuous improvement efforts by promoting best practices for processes and technologies.
• Demonstrated commitment to organizational core values, fostering a culture of excellence.
• Managed customer complaints, resolving issues and adjusting policies to meet evolving needs.
• Evaluated employee performance and provided coaching and training to improve areas needing development.

• Managed 13-25 daily reviews of new admissions and continued stay cases.
• Served as a subject matter expert on NICU admissions, providing specialized guidance and support.
• Played a key role in launching the NICU program, including policy implementation, claims review, and tracking.
• Collaborated with membership and claims departments to ensure accurate case creation and review.
• Evaluated medical guidelines and benefit coverage to determine service appropriateness.
• Developed and implemented solutions for complex and irregular requests.
• Provided medical claims review coverage during staff absences.
• Processed prior authorizations for services requiring notification

• Secured authorizations from multiple insurance carriers for various levels of care.
• Conducted high-volume reviews of patient charts to determine medical necessity based on established guidelines.
• Communicated with insurance agents regarding ICD-10 and CPT codes.
• Collaborated with the Medical Director on clinically complex patient reviews.
• Performed comprehensive utilization reviews, utilizing cost containment strategies.
• Served as a subject matter expert on NICU revenue codes.
• Provided training and support to team members on OB and NICU cases.

40 bed Level IIIb NICU unit.

• Provided comprehensive, family-centered care to critically ill neonates in a 40-bed Level IIIb NICU.
• Delivered complex care, including HFOV/INO/PICC/UAC/UVC/PALS/Chest Tubes.
• Provided support, education, and comfort to families, fostering strong relationships.
• Attended high-risk deliveries and provided immediate care to newborns.
• Ensured consistent communication with physicians, implementing orders, and collaborating on patient care.
• Chaired the Infection Control Team, leading initiatives to reduce CLABSIs and promote infection control awareness.
• Co-created and co-chaired the Mentor Program, providing support and guidance to new staff.
• Served as a member of the Unit Practice Committee, contributing to evidence-based care practices.
• Participated in the Extremely Low Gestational Age Newborn Team, contributing to research and improved outcomes.
• Served as a Professional Preceptor, orienting and supporting new staff.
• Served as a Clinical Instructor, teaching and mentoring senior nursing students.
• Participated in the Leadership Team, contributing to quality improvement and staff development.

• Recognized for outstanding academic performance, graduating Summa Cum Laude with a 4.0 GPA and consistently named to the President's List. Honored with the SAINT Award and elected to Saint Luke's College Honor's Society, while actively contributing to the SLSNA Community Committee.