Sabrina Alexander
Wilmington,OH
Summary
Dynamic Clinical Appeals Specialist at Optum Insight Clinical Services with expertise in medical coding and compliance regulation. Proven ability to enhance claims evaluation processes, ensuring accuracy and adherence to federal standards. Strong communicator and problem solver, consistently driving process improvements and training development to elevate team performance and patient outcomes. Results-driven individual with a solid track record in delivering quality work. Known for excellent communication and teamwork abilities, with a commitment to achieving company goals and delivering exceptional service. Passionate about continuous learning and professional development. Experienced in fast-paced environments and adaptable to last-minute changes. Thrives under pressure and consistently earns high marks for work quality and speed.
Overview
17
17
years of professional experience
1
1
Certification
Work History
Clinical Appeals Specialist, Clinical Documentation
Optum Insight Clinical Services
06.2023 - Current
- Ensures compliance with all types of health plans reviewing claims for coding analysis, and root causes for denials.
- Comprehensive reviews ensuring accuracy of charges while remaining in compliance of all federal and state regulations.
- Acts as a knowledgeable resource to support coders and other team members.
- Reviews records for inpatient hospital, SNF, LTAC, Rehab, and outpatient cases using InterQual criteria/MCG guidelines, coding accuracy, and medical necessity ensuring appropriate diagnose.
- Maintains compliance with Federal and state regulations
- Continuously identifies areas for process improvement
- Prioritizes work to meet company's turnaround time requirements.
- Prepares case for administrative law hearings
- Performs utilization reviews from pre-service to post service.
Subject Matter Expert Team Lead, Clinical Documentation
Optum Health
05.2017 - 06.2023
- Contributes to user acceptance testing and facilitates integration of new processes.
- Addresses D.O.I. complaints, escalations, and FAST cases with effective solutions.
- Acts as a knowledgeable resource to support other team members.
- Provides comprehensive training by reviewing all relevant process guides, job aids, and SOPs with trainees.
- Conducted comprehensive reviews of medical claims, both inpatient and outpatient, according to MCG/InterQual/Federal/State mandates, and medical policy guidelines.
- Served as a subject matter expert, sharing knowledge and expertise with colleagues to improve overall quality and efficiency.
- Provided valuable assistance with education and auditing to support the ongoing development of team members.
- Updated, maintained, created, and revised all process guidelines, and letter templates.
- Expertly trained new staff on complex review types, fostering a culture of continuous learning and growth.
- Worked closely with Medical Directors to ensure compliance and optimize outcomes.
- Possessed advanced computer skills, facilitating effective data management and analysis.
- Proactively identifies opportunities for creating or updating process guides.
- Reviews records for inpatient hospital, SNF, LTAC, Rehab, and outpatient cases using InterQual criteria/MCG guidelines, coding accuracy, and medical necessity ensuring appropriate diagnose.
- Reviewed process guides to ensure compliance with federal and state regulations were maintained.
- Continuously identifies areas for process improvement.
- Prioritizes work to meet company's turnaround time requirements.
- Involved in Project management and process improvement of the MCR department.
Case Manager
Clinton Memorial Home Care
Wilmington, OH
05.2009 - 06.2015
- Facilitated referrals to other healthcare providers as needed.
- Coordinated with healthcare team to establish, enact and evaluate patient care plans.
- Monitored changes in patient health status and reported to physician or other healthcare professionals as necessary.
- Collaborated with interdisciplinary team members to ensure quality patient outcomes.
- Initiated referrals to other healthcare professionals when appropriate for additional treatment needs or therapies such as physical therapy or occupational therapy.
- Maintained accurate documentation of all visits according to agency policies and procedures.
- Maintained strict patient data procedures to comply with HIPAA laws and prevent information breaches.
Transitional Care Manager/Clinical Care Manager
Optum
Wilmington, OH
07.2011 - 05.2015
- Supported quality initiatives by collecting data regarding outcomes following transitions from acute care facilities.
- Adhered to regulatory standards such as HIPAA compliance when handling confidential information pertaining to patients' transitions.
- Established relationships with external organizations providing services necessary for successful transitions.
- Identified key sources of information that could be helpful to patients, families, and other individuals.
- Determined organizational policies regarding program eligibility, requirements and benefits.
- Provided education to patients and families on self-management skills such as medication management, nutrition, exercise.
- Coordinated discharge planning activities with multidisciplinary teams in order to provide seamless transitions of care.
- Collaborated with healthcare professionals, families, and caregivers to ensure continuity of care during the transition process.
- Ensured compliance with applicable laws, regulations and standards pertaining to health care information management systems.
- Communicated with physicians, nurses, coders, administrators, and other personnel regarding issues related to data abstraction.
- Extracted data from medical records into computerized databases.
- Set up patient charts and documented information in various company software.
- Reviewed patient records to accurately abstract and assign codes for diagnosis and procedures.
- Prepared presentations summarizing findings based on collected data.
Health Coach/Advocate
Optum
Wilmington, OH
04.2008 - 07.2011
- Championed quality improvement measures through Qfiniti audits and VCC reporting.
- Mentored new employees, sharing knowledge and expertise to ensure a high level of performance across the team.
- Empowered clients to make informed decisions about their healthcare by providing guidance and support, resulting in fewer unnecessary emergency room visits.
- Expertly triaged patient calls and provided evidence-based advice, enhancing patient outcomes and satisfaction.
- Utilized computerized Resource and Patient Management System (RPMS) and Electronic Health Record (EHR) system.
- Assessed patient conditions, monitored behaviors and updated supervising physicians with observations and concerns.
- Utilized EHR systems effectively for documentation purposes in accordance with HIPAA regulations.
- Managed triage phone calls by providing appropriate advice or referring callers to their primary care provider or other specialists when necessary.
Education
Bachelor of Science - Nursing
Ohio University
Athens05-2010
Associate Degree - Nursing
Good Samaritan College of Nursing
Cincinnati, OH05-2004
Skills
- Medical coding
- Compliance regulation
- CDI methodologies
- Excellent time management skills
- Medical terminology
- Claims Evaluation
- Communication Skills
- Proven ability to balance multiple priorities
- Data accuracy
- Record analysis
- Task Management
- Advanced understanding of the UR program from start to finish
- Utilization review
- Process improvement
- InterQual criteria
- Case management
- Coding accuracy
- Medical necessity
- Claims analysis
- Regulatory compliance
- Training development
- Problem solving
- Root cause analysis
- Time management abilities
- Prior authorization processing
- Continuous learning mindset
- Claims processing
- Multitasking
Certification
- Ohio Registered Nurse License, 311640, compact state
- Certified Case Manager
- MCG Certified
- Proficient in reviewing per InterQual guidelines.
- Actively studying for Coding certification
Personal Information
Title: RN, BSN, CCM
Accomplishments
- Former Optum Super Hero
- Nominated for Optum Sages
References
References available upon request.
Timeline
Clinical Appeals Specialist, Clinical Documentation
Optum Insight Clinical Services
06.2023 - Current
Subject Matter Expert Team Lead, Clinical Documentation
Optum Health
05.2017 - 06.2023
Transitional Care Manager/Clinical Care Manager
Optum
07.2011 - 05.2015
Case Manager
Clinton Memorial Home Care
05.2009 - 06.2015
Health Coach/Advocate
Optum
04.2008 - 07.2011
Bachelor of Science - Nursing
Ohio University
Associate Degree - Nursing
Good Samaritan College of Nursing
Similar Profiles
Flordeliza ArnadoFlordeliza Arnado
Admin Asst / Business Segment Liaison at Optum Health Risk Operations & Enablement Clinical ServicesAdmin Asst / Business Segment Liaison at Optum Health Risk Operations & Enablement Clinical Services
Tracy Kay FritzTracy Kay Fritz
HouseCalls Nurse Practitioner at United Health Group/Optum Clinical Services, Inc.HouseCalls Nurse Practitioner at United Health Group/Optum Clinical Services, Inc.
Lisa SchulzLisa Schulz
Optimal Practice Insight| Client Success Manager at Optum insight/ Optum Behavioral Care HealthOptimal Practice Insight| Client Success Manager at Optum insight/ Optum Behavioral Care Health
Wendy Jo DaughertyWendy Jo Daugherty
Blanchester Alumni Association Committee Member at Blanchester Alumni Association CommitteBlanchester Alumni Association Committee Member at Blanchester Alumni Association Committe
James CooperJames Cooper
Assistant Chief Administrator - Internal Controls at TS Tech Americas, Inc.Assistant Chief Administrator - Internal Controls at TS Tech Americas, Inc.