Tanisha Butler
Prentiss,MS
Summary
Collaborative HEDIS Nurse Reviewer recognized for producing accurate, timely reports and meeting stringent deadlines. Well-versed in cataloging patient data and records and developing new methods of managing patient information. Familiar with structures and functions of complex database technologies paired with extensive understanding of vocabulary and commonalities of large information systems. Able to identify the need for process changes and documentation updates and/or development. Proficiently able to create, maintain, and update documentation when appropriate in accordance with document control process.
Overview
12
12
years of professional experience
Work History
HEDIS Review Nurse
United Healthcare, UHG, Optum
11.2023 - Current
- Developed and updated health information systems and interfaces.
- Led, facilitated, and attended focus groups and meetings to strategize workflow issues.
- Implemented healthcare systems for patient status monitoring, quality tracking and home care management.
- Worked with product engineering team to define clinical requirements and assist with testing.
- Applied knowledge, data, information and workflow to develop evidence-based models for health information technology solutions.
- Operated computer-based systems to retrieve and store information and records.
- Worked closely with subject matter experts to develop solutions and improvements for clinical systems.
LPN
Cardiovascular Institute Of MS
10.2022 - Current
- Provide review for all outpatient and ancillary prior authorization requests for medical appropriateness and medical necessity using appropriate criteria, referring those requests that fail review to the medical director for second level review and determination
- Responsible for entering data into a HEDIS software system and review of medical records and abstraction of critical HEDIS data
- Comply with HIPPA laws and regulations
- Communicate with clinical team and referral sources for reference status
- Evaluated patient histories, complaints, and current symptoms
- Reported findings to quality departments after conducting routine restraint audits and worked with team to devise corrective actions for deficiencies
- Receives HEDIS assignment and independently contacts offices, schedules appointments, arranges to get appropriate material to the offices on a timely basis
- Functioned as a remote HEDIS nurse and performed medical record analysis using electronic medical record
- Conducts rate negotiation with non-network providers, utilizing appropriate CMAC, as well as document rates negotiation accurately for proper claims adjudication
- Maintain up-to-date knowledge of State and Federal hospital regulation.
Clinical LPN
Merit Health Central
04.2012 - 10.2022
- Analyze data using all applicable law regulations (state and/or government process documents, and other sources as defined by the client contract.) Work independently on specific situations or on a team to resolve problems and deviations according to current established practices; and obtain advice where precedents are unclear or not available from the client
- HEDIS, chart abstract and pre-authorization in healthcare setting
- Functioned as a remote HEDIS nurse and performed medical record analysis using electronic medical record
- Ability to maintain a strong reputation for achieving high levels of patient satisfaction, as we as, collaborating with leadership to devise initiatives for improving nursing satisfaction, retention, and morale
- Great experience with resolving all customers and client complaints in a professional manner while prioritizing customer/client satisfaction
- Excellent communication and interpersonal skills
- Familiar with industry standards and requirements
- Managing duties to facilitate smooth workflow and operational efficiency.
Education
Associate of Applied Science - License Practical Nursing -
Jones Junior Community College
Ellisville, MS12.2010
Associate of Arts - Medical Billing and Coding/Transcription - undefined
Pearl River Community College
Poplarville, MS05.2009
Skills
- Scheduling appointments
- Follow-up skills
- Performance Management
- Customer Service
- Teamwork and Collaboration
- Regulatory Compliance
- Excellent Communication
- Quality Assurance
- Multitasking and Organization
- Analytical Skills
Timeline
HEDIS Review Nurse
United Healthcare, UHG, Optum
11.2023 - Current
LPN
Cardiovascular Institute Of MS
10.2022 - Current
Clinical LPN
Merit Health Central
04.2012 - 10.2022
Associate of Applied Science - License Practical Nursing -
Jones Junior Community College
Associate of Arts - Medical Billing and Coding/Transcription - undefined
Pearl River Community College
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