Samantha Ebersole
Silver Spring,MD
Summary
Nurse Specialist with expertise in diverse nursing specialties. Proficient in patient care, treatment administration, and nursing staff supervision. Effective communication, problem-solving, and leadership skills have led to notable enhancements in patient satisfaction and healthcare delivery.
Overview
29
29
years of professional experience
1
1
Certification
Work History
Nurse Specialist II
Department of Health Care Finance
Washington, DC
12.2015 - Current
- Conducting audits on District health care providers according to the Generally Accepted Government Auditing Standards (GAGAS) to evaluate quality of care and to ensure compliance with federal and District laws and rules, policy and procedures, provider’s contract, and billing manual
- Researching, interpreting and applying Federal laws, CMS, District regulations, policies and procedural guidelines that apply to different services covered by the programs to audit
- Reviewing policies and procedures, internal controls, claims adjudication, medical records, and appeals to determine compliance with Federal and State Medicaid rules, CMS regulations, and other applicable guidelines
- Conducting claims data mining and analytics to identify provider’s billing patterns and trends to prioritize areas of high risk and target services to audit
- Analyzing, and interpreting data from MMIS claims processing to determine appropriate payments regarding Fee for Service FFS claims and Managed Care Organizations MCO encounters
- Recovering overpayments as a result of the findings on the audit, and monitoring recoupment actions for each audit to ensure all funds are recovered
- Requesting a Corrective Action Plan (CAP) from the provider, and monitoring effectiveness of corrective actions to avoid recurrence of the deficiencies found
- Writing audit reports including the summary of findings, and recommendations to mitigate program vulnerabilities and to reduce improper payments
- Compiling, reviewing and analyzing medical records, progress notes, and other documentation substantiating claims to ensure that claims were paid in accordance with specific guidelines covering the type of service, the medical necessity of the service provided, and validating the service delivered as it was pre authorized and billed
- Providing educational resources and technical assistance to providers, external audit contractors, and other District agencies regarding audit findings, risk assessments and other regulations pertaining to the healthcare services delivered
- Track data identifying trends in vulnerable areas and participate in the analysis of programs susceptible to waste, fraud or abuse
- Maintaining up-to-date notes, documentation collected as evidence during the audit for each case on the case tracking system (i-Sight)
- Making recommendation or intervention strategies to correct or prevent abusive practices, including proposals to recover inappropriate payments
- Participate in focus groups aimed at improving quality on health care services, and coordinate with stakeholders to recommend and develop solutions to program vulnerabilities.
Nurse Care Manager
Health Services for Children with Special Needs
Washington, DC
03.2014 - 11.2015
- Coordinated with Early Intervention team to provide authorization of services for members in the Early Intervention (EI) Program
- Authorized Early Intervention services required per the Individualized Plan and searched for providers to implement those services
- Managed data base and monthly reports to assess the deadline of services implemented
- Managed data base regarding the current number of referrals of new children in the Early Intervention Program
- Communicated with Primary Care Providers, therapists, and specialists to implement care coordination plans, while following up with the relevant healthcare team to achieve our goals
- Participated in initial and ongoing assessments through home visits to identify needs and barriers to access of care
- Monitored progress and outcomes of the referred and authorized services
- Maintained documentation necessary to fulfill regulatory, accreditation, performance, statistical, and quality requirements
- Educated patients and their families regarding, health condition management, promotion, prevention and safety
- Reported adverse events and complaints to Quality Assurance Department
- Coordinated transition to home after in-patient admissions.
Interpreter Services Coordinator
Providence Hospital
Washington, DC
07.2008 - 12.2013
- Coordinated interpretive services with healthcare providers through the hospital to facilitate effective communication with patients when providing care, treatment, and services to deaf and hard of hearing, non-English or limited English proficient patients
- Acted as liaison for staffing with La Clinica del Pueblo DC, to provide face to face interpretation
- Managed daily operations of six interpreters to provide face to face interpretations and interpreter services availability upon request
- Assigned workflows and shift schedule to interpreters to ensure 24 hours of interpreter coverage in all units of the hospital
- Developed Language Access plan, policies and procedures related to interpreter service, including the process and procedures to work with Limited or non English proficiency population and deaf or hard of hearing patients
- Ensured compliance with the Americans with Disabilities Act (ADA), Language Access Act to provide effective means of communication for patients, family members and hospital visitors
- Introduced all new employees on how to use interpreter services and communication aids during New Employee Orientation and annually thereafter
- Monitored daily interpretations logs to analyze hospital units with more demand, reduced overtime expenses from 10% to less than 3% within two months by efficient scheduling without compromising interpretation coverage
- Reviewed and approved the translation of vital healthcare documents (inform consents, discharge instructions, etc.) from English into different languages
- Coordinated the implementation and deployment of the video remote interpretation services available for spoken languages and sign language
- Cut overspending 20% of face-to-face interpretation by replacing it with video remote interpretation
- Increased patient satisfaction among non-English and Limited English proficiency patients according to surveys
- Analyzed performance metrics to prepare timely reports for leadership on compliance with language access
- Managed outreach in healthcare events for the Latino community, translated documents and brochures related to screening tests, prevention, and healthcare education
- Developed and organized trainings to educate healthcare providers to work with interpreters in different departments and units in the hospital
- Monitored the budget for the language access program, with the expenses for telephonic, face to face interpretation, video remote interpretation, translation of documents, and signage of interpreter services
- Researched vendors and analyzed proposals to contract video remote interpretation, telephonic and translation services
- Ensured the deployment, monitoring, and quality control of Language Preference data collection.
Medical Biller
Washington Gastroenterology, P.C.
Washington, DC
02.2006 - 06.2008
- Trained and onboarding new hires to complete the clinical records review and complete the CMS-1500 forms to submit the bill for services rendered to the insurance companies
- Coordinated the planning, organization and the implementation of the workflow for four staff on the billing unit to submit promptly the claims keeping the efficiency of the revenue cycle
- Identified training needs, created training plans, and deployed effective training programs to other billers to improve the revenue cycle by decreasing the claims denied
- Assigned medical and procedural codes ICD-9, CPT and HCPCS to medical charges for out-patient and in-patient services
- Reviewed and abstracted information from medical records and operative reports to support services delivered to submit the claim
- Contacted medical providers to complete and/or clarify medical documentation required to submit the claims
- Posted payments from patients and claims paid by insurance companies using Mysis Software application
- Submitted claims to different payers following the guidelines of each insurance contract
- Followed up on claims denials, and presented, supported and organized appeals on denied payments
- Reviewed demographic and validated insurance information entered in the registration system by the front desk staff in order to properly submit claims
- Contacted patients with outstanding balances and responded to inquiries concerning billing issues.
Project Manager
A.G.S Colombia (Management Consultants and Healthcare Auditors)
Bogota, Colombia South America
06.1996 - 12.2001
- Guided, planned, and coordinated the activities to be developed in each project
- Performed concurrent and retrospective medical records reviews to ensure correct payment of the claim
- Including the right procedure code, the number of units, the medical necessity and sufficient documentation to substantiate the claim
- Oversaw training program in areas of coding, documentation, and compliance for collaborative and interdisciplinary personnel
- This included preparation of training materials, reviewing educational audits, while developing new methods and processes to improve coding efficiency
- Served as a resource for physicians to help link ICD-9-CM coding guidelines and medical terminology to improve accuracy of patient severity of illness, risk of mortality and final code assignment
- Complied with policies and procedures related to confidentiality of medical records
- Participated in the development, innovation, operation and implementation of health care policies and protocols of care for different clinics assigned.
Auditing Evaluator
Convida Empresa Promotora de Salud EPS
Bogota, Colombia South America
06.1995 - 05.1996
- Reviewed utilization of resources and pre-authorization for medical services in network
- Performed concurrent record reviews on selected cases based on sample selection criteria and initiates queries as appropriate
- Monitored and evaluated effectiveness of concurrent chart review and query outcomes at designated intervals
- Led the interdisciplinary team to achieve optimal clinical outcomes for the out-patient, acute, and post-hospital phases of care
- Communicated with healthcare providers throughout clients’ hospitalization to ensure appropriate utilization management and cost-effective care
- Interacted with clinical departments to clarify components of the treatment for discharge plan
- Analyzed indicators promoting healthcare utilization review process and applicable standards
- Identified opportunities for intradepartmental and interdepartmental operational improvements based on record review findings
- Collected, analyzed and reported the findings of the auditing by submitting a comprehensive report for each audited facility
- Evaluated quality assurance for health education programs including complex chronic disease management, wellness, counseling, resource referral and support group.
Education
Bachelor of Science in Nursing -
Sacred Heart University
Puerto Rico01.2013
Certificate in Medical Coding -
Albuquerque Technical Vocational Institute, Community College
Albuquerque, NM01.2004
Occupational Health Specialist -
Escuela Colombiana de Medicina
Bogotá, Colombia01.1996
Physician -
Escuela de Medicina Juan N. Corpas
Bogotá, Colombia01.1992
Skills
- Microsoft Office (Word, Excel, PowerPoint, Access, Outlook)
- Power BI
- EMR (Electronic Medical Records)
- Statistical Analysis System (SAS)
- Report Writing
- Data Analysis
- Healthcare management
- Staff Training
Certification
- Registered Nurse, District of Columbia, RN1032001
- Registered Nurse, Maryland, R208443
- Certified Professional Medical Auditor, American Association Professional Coders (AAPC)
Timeline
Nurse Specialist II
Department of Health Care Finance
12.2015 - Current
Nurse Care Manager
Health Services for Children with Special Needs
03.2014 - 11.2015
Interpreter Services Coordinator
Providence Hospital
07.2008 - 12.2013
Medical Biller
Washington Gastroenterology, P.C.
02.2006 - 06.2008
Project Manager
A.G.S Colombia (Management Consultants and Healthcare Auditors)
06.1996 - 12.2001
Auditing Evaluator
Convida Empresa Promotora de Salud EPS
06.1995 - 05.1996
Bachelor of Science in Nursing -
Sacred Heart University
Certificate in Medical Coding -
Albuquerque Technical Vocational Institute, Community College
Occupational Health Specialist -
Escuela Colombiana de Medicina
Physician -
Escuela de Medicina Juan N. Corpas
Similar Profiles
Lucy T. Wilson-KearLucy T. Wilson-Kear
Long-Term Care Project Coordinator at Department of Health Care FinanceLong-Term Care Project Coordinator at Department of Health Care Finance
Morgan GloverMorgan Glover
Management Analyst- Intern ( GS-4) at Department Health Care FinanceManagement Analyst- Intern ( GS-4) at Department Health Care Finance
Kayli BlankenshipKayli Blankenship
Senior Administrative Assistant at KDHE- Division Of Health Care FinanceSenior Administrative Assistant at KDHE- Division Of Health Care Finance