Sharon Acha
Burleson,TX
Summary
Licensed Registered Nurse with 6+ years of clinical and utilization review experience, specializing in No Surprises Act (NSA) Independent Dispute Resolution (IDR) nurse arbitration. Proven ability to independently review complex case submissions, apply federal NSA regulations, and produce clear, defensible written determinations within strict timelines. Highly detail-oriented, deadline-driven, and experienced in fully remote, high-volume review environments aligned with C2C Innovative Solutions standards.
Overview
7
7
years of professional experience
Work History
No Surprises Act Nurse Arbitrator / Nurse Reviewer
C2C Innovative Solutions
11.2023 - Current
- Conduct independent NSA IDR nurse reviews for out-of-network payment disputes in accordance with federal regulations and C2C quality requirements.
- Review and analyze complete case submissions, including medical records, superbills, contracts, and supporting documentation from both initiating and non-initiating parties.
- Apply NSA statutory criteria, federal guidance, and prior contractual agreements to evaluate good-faith negotiation efforts and payment reasonableness.
- Assess submitted offers and determine the prevailing party based on regulatory standards and evidentiary support.
- Draft well-structured, audit-ready written rationales supporting arbitration determinations.
- Identify documentation gaps, inconsistencies, and recurring payer or provider trends affecting dispute outcomes.
- Manage caseloads independently while consistently meeting strict turnaround times and regulatory deadlines.
Clinical Review Technician
Prime Therapeutics
06.2022 - 11.2023
- Reviewed prescription requests requiring prior authorization, step therapy, formulary exceptions, quantity limits, and coverage determinations.
- Verified member eligibility, clinical criteria, and completeness of documentation to ensure compliance with pharmacy regulations.
- Collaborated with providers, pharmacists, and insurance representatives to resolve authorization issues and prevent treatment delays.
- Maintained accurate, audit-ready documentation of review decisions and outreach activities.
- Supported high-volume review operations while meeting productivity and quality benchmarks.
Home Health Nurse / Case Manager
Assure Best Care
02.2021 - 05.2022
- Conducted comprehensive in-home patient assessments addressing physical, emotional, and social needs.
- Developed and implemented individualized care plans in collaboration with interdisciplinary teams.
- Provided skilled nursing services including medication administration, wound care, infusion therapy, and patient education.
- Monitored patient progress and ensured timely, accurate clinical documentation in compliance with regulatory standards.
Registered Nurse – Medical/Surgical
Tucson Medical Center
07.2019 - 02.2021
- Delivered acute care nursing services for patients with COPD, CHF, stroke, diabetes, fractures, and complex medical conditions.
- Performed assessments, coordinated care with interdisciplinary teams, and documented care in EMR systems.
- Managed admissions, discharges, and clinical escalations in a fast-paced hospital environment.
Registered Nurse
Foothills Rehabilitation Center
12.2018 - 07.2019
- Provided skilled nursing care including medication administration (PO, IM, IV, G-tube).
- Performed wound care (including wound vac therapy), tracheostomy care, and urinary catheterization.
- Supported admissions, care planning, and interdisciplinary coordination.
Education
Bachelor of Science - Nursing
Indiana State University
Terre Haute, IN08-2018
Skills
- No Surprises Act (NSA) IDR Arbitration
- Independent Nurse Review & Determinations
- Medical Record, Superbills & Contract Review
- Federal Healthcare Regulatory Compliance
- Written Decision & Rationale Development
- Case Management & Deadline Management
- Quality Assurance & Audit Readiness
- Remote, High-Volume Review Environments
- EMR & Claims Review Systems
Timeline
No Surprises Act Nurse Arbitrator / Nurse Reviewer
C2C Innovative Solutions
11.2023 - Current
Clinical Review Technician
Prime Therapeutics
06.2022 - 11.2023
Home Health Nurse / Case Manager
Assure Best Care
02.2021 - 05.2022
Registered Nurse – Medical/Surgical
Tucson Medical Center
07.2019 - 02.2021
Registered Nurse
Foothills Rehabilitation Center
12.2018 - 07.2019
Bachelor of Science - Nursing
Indiana State University