Summary
Overview
Work History
Education
Skills
Timeline
Generic

Tanya Dickerscheid

HAMILTON

Summary

Compassionate and results-driven Licensed Practical Nurse with a Multistate License and over 24 years of clinical and leadership experience, seeking to leverage extensive background in remote case management, utilization review, and telehealth. Demonstrated expertise in claims submission, adjustment, and review, with a strong understanding of Medicare and Medicaid compliance, regulatory requirements, and interdisciplinary care coordination. Adept at transcribing clinical documentation, streamlining workflows, and delivering high-quality, patient-centered care in both clinical and remote settings. Proven ability to mentor teams, manage prior authorizations, and support continuous quality improvement. Eager to contribute to a dynamic healthcare organization committed to excellence and innovation.

Overview

24
24
years of professional experience

Work History

Private Duty Nurse for Family Member

(self Employed)
01.2021 - 02.2025
  • Delivered personalized, comprehensive 24 hour / 7 days per week nursing care to a family member with a chronic illness and comorbidities related to Thalidomide Poisoning while in Utero.
  • Managed complex medical needs in a home setting. Administered medications, monitored vital signs, and monitored / managed symptoms to 0ptimize health and prevent complications.
  • Coordinated care with healthcare providers, scheduled medical appointments, and ensured adherence to treatment plans.
  • Provided wound care, full assist with all activities of daily ADL, and supported mobility to maintain comfort and independence.

LPN Office Nurse /Medical Office Manager

Ashok Kejriwal, MD
08.2016 - 12.2020
  • Assisted with minor surgical procedures, ensuring proper sterilization techniques and adherence to safety protocols.
  • Coordinated referrals to specialists when necessary, ensuring seamless transitions of care for patients within the healthcare system.
  • Served as a liaison between patients and healthcare providers, facilitating clear communication regarding treatment plans and expectations.
  • Managed inventory of medical supplies within the office, ensuring adequate stock levels while minimizing waste through effective organization strategies.
  • Demonstrated adaptability by efficiently managing unexpected changes in schedules or staffing situations without compromising patient care quality or timeliness of services rendered.
  • Provided health education to patients on various topics such as medication management, disease prevention, and self-care strategies.
  • Conducted thorough assessments of vital signs, lab results, and physical status to identify potential concerns and inform appropriate interventions.
  • Streamlined appointment scheduling processes, resulting in reduced wait times and increased patient satisfaction.
  • Maintained accurate medical records for over 300 patients, ensuring timely updates and efficient communication between healthcare providers.
  • Collaborated with interdisciplinary team members to develop individualized care plans for each patient based on their specific needs.
  • Prepared patients for diagnostic testing procedures by explaining the process, providing reassurance, and answering any questions they may have.
  • Participated in continuing education opportunities for professional development purposes while staying apprised of industry best practices and emerging healthcare trends.
  • Handled all aspects of prior authorizations for medications, procedures (oral, infusion,
    injectables), imaging, DME, home health, and specialty referrals, ensuring timely follow-up and detailed record-keeping.
  • Conducted telehealth patient triage and virtual follow-ups to support remote care delivery.
  • Transcribed office visit notes and hospital rounding notes for the physician’s documentation and billing purposes.
  • Collaborated with billing departments and insurance payers to resolve claim denials and discrepancies, facilitating prompt reimbursement.
  • Reviewed authorization requirements and submitted PA as neeed. Reviewed approvals to verify coverage details prior to claims processing, reducing claim rejections. Appealed Denied PA's and Claim's.
  • Provided clinical documentation and coding support for claim submission, ensuring claims reflected appropriate services rendered
  • Hired, managed, developed and trained staff, established and monitored goals, conducted performance reviews and administered salaries for staff.
  • Optimized organizational systems for payment collections, AP/AR, deposits, and recordkeeping.
  • Created reports, presentations and other materials for executive staff.
  • Improved office operations by automating client correspondence, record tracking and data communications.
  • Implemented project management techniques to overcome obstacles and increase team productivity.
  • Analyzed and solved multi-faceted problems that effected executive leaders and business initiatives.

Prior Authorization Supervisor – Medicaid/Medicare Specialist

Centene Corporation - Sunshine State Health Plan
08.2012 - 10.2015
  • Supervised a team of nurses and intake staff handling prior authorization requests for inpatient, outpatient, specialty medications, DME, home health, and ancillary services for HMO members including Medicaid, Medicare, and Dual Eligible populations.
  • Served as the clinical escalation point for complex and high-acuity cases requiring next-level review prior to medical director determination, ensuring sound clinical judgment aligned with InterQual/MCG and CMS/HEDIS guidelines.
  • Personally reviewed and authorized high-complexity cases including transplant evaluations, oncology, behavioral health, and post-acute services.
  • Led resolution of challenging authorization issues, claims denials, and provider escalations, working closely with appeals, compliance, and provider relations departments to ensure timely resolution and member access to care.
  • Maintained and enforced strict adherence to state and federal regulatory requirements, including timely authorization turnaround standards, documentation compliance, and audit readiness.
  • Compiled and submitted monthly and quarterly reports to state agencies, including authorization metrics, timeliness reports, and quality indicators.
  • Partnered with the concurrent review and discharge planning teams to ensure seamless transitions of care, appropriate length of stay, and safe discharges to home or post-acute settings.
  • Collaborated with pharmacy, behavioral health, utilization review, and care management teams on interdisciplinary case rounds and policy improvements.
  • Developed training tools and standard operating procedures (SOPs) for authorization workflows, contributing to improved consistency, audit outcomes, and staff performance.
  • Led internal quality initiatives and coached staff on clinical decision-making, documentation best practices, and regulatory interpretation.
  • Oversaw daily operations of the department, ensuring smooth workflow and timely completion of tasks.
  • Resolved conflicts among team members promptly, maintaining a harmonious working environment conducive to productivity.
  • Enhanced communication within the team by holding regular meetings and encouraging open dialogue among all members.
  • Demonstrated commitment to the organization''s core values, leading by example and fostering a culture of excellence.

Prior Authorization Nurse / Case Management Nurse

Centene Corporation - Buckeye Community Health Plan / Sunshine State Health Plan
07.2010 - 08.2012
  • Streamlined the prior authorization process, reducing wait times and improving overall efficiency.
  • Supported organizational initiatives focused on improving patient access to care by providing expert guidance on the prior authorization process.
  • Conducted real-time clinical reviews of inpatient hospitalizations, ensuring medical necessity and appropriate level of care based on InterQual, MCG, and payer-specific criteria.
  • Collaborated with providers, discharge planners, and multidisciplinary teams to coordinate timely transitions of care and reduce avoidable hospital days.
  • Initiated and tracked continued stay reviews, communicating directly with attending physicians and hospital staff to obtain clinical updates and justify medical necessity.
  • Monitored patient progress, flags for delays in care, and escalated complex cases to medical directors for second-level review.
  • Participated in interdisciplinary team meetings, collaborating with other healthcare professionals to ensure seamless coordination of care for patients requiring prior authorizations.
  • Managed comprehensive prior authorization processes for a broad range of services including DME, home health care, inpatient and outpatient services, pharmaceuticals, and ancillary services for Medicaid and Medicare populations.
  • Specialized in case management for high-risk Obstetrics (OB) patients, coordinating care plans to optimize maternal and fetal outcomes.
  • Conducted detailed clinical reviews of authorization requests, verifying medical necessity in compliance with company policies and regulatory guidelines.
  • Developed and monitored individualized care plans to ensure continuity and quality of care, working collaboratively with multidisciplinary teams and external providers.
  • Served as a key clinical resource for second-level reviews and appeals, partnering closely with physicians and specialists to evaluate denial rationales and support overturning inappropriate denials.
  • Communicated effectively with providers to clarify clinical information, expedite approvals, and resolve complex cases in a timely manner.
  • Participated in ongoing quality assurance efforts by auditing prior authorization cases and contributing to process improvement initiatives.
  • Expedited urgent requests for prior authorization, ensuring timely access to critical medical treatments.
  • Expedited patient throughput within the hospital setting by identifying barriers to timely discharges or transfers and working collaboratively with stakeholders to address them.
  • Streamlined the utilization review process for more efficient case management and improved resource allocation.
  • Conducted real-time clinical reviews of inpatient hospitalizations, ensuring medical necessity and appropriate level of care based on InterQual, MCG, and payer-specific criteria.
  • Collaborated with providers, discharge planners, and multidisciplinary teams to coordinate timely transitions of care and reduce avoidable hospital days.
  • Initiated and tracked continued stay reviews, communicating directly with attending physicians and hospital staff to obtain clinical updates and justify medical necessity.
  • Monitored patient progress, flags for delays in care, and escalated complex cases to medical directors for second-level review.
  • Managed comprehensive prior authorization processes for a broad range of services including DME, home health care, inpatient and outpatient services, pharmaceuticals (oral/IV), chemotherapy, and ancillary services for Medicaid and Medicare populations.
  • Specialized in case management for high-risk Obstetrics (OB) patients, coordinating care plans to optimize maternal and fetal outcomes.
  • Conducted detailed clinical reviews of authorization requests, verifying medical necessity in compliance with company policies and regulatory guidelines.

Appeals and Denials LPN

Amerigroup Community Health Plan
04.2005 - 07.2010
  • Reviewed and processed member and provider appeals, grievances, and reconsiderations for denied services under Medicaid, Medicare, and Dual Eligible HMO plans, ensuring compliance with CMS, NCQA, and state regulations.
  • Conducted comprehensive clinical reviews to determine medical necessity, appropriateness of care, and accuracy of denial rationale using evidence-based criteria such as InterQual and MCG.
  • Collaborated closely with medical directors on second-level reviews and overturn decisions for complex or high-risk cases.
  • Prepared detailed clinical summaries, timelines, and case arguments for formal state fair hearings and regulatory appeals.
  • Communicated with physicians, hospitals, and providers to obtain supporting documentation and clarify treatment plans to strengthen appeal cases.
  • Tracked appeals timelines and ensured all responses were completed within regulatory turnaround time (TAT) requirements.
  • Responsible for regulatory compliance reporting through Oracle to the State of Ohio.
  • Participated in root cause analysis for trends in denials and grievances, helping identify gaps in provider documentation and payer processes.
  • Contributed to policy refinement and training initiatives to reduce preventable denials and support accurate decision-making.
  • Maintained meticulous records and reporting to ensure audit readiness and regulatory compliance.

Staff Development Nurse

The Meadows
08.2004 - 01.2005
  • Designed and delivered orientation and ongoing clinical education programs to improve nursing competencies, support regulatory compliance, and promote high-quality patient care.
  • Assessed staff performance and learning needs, providing targeted training aligned with current clinical standards and facility policies.
  • Partnered with leadership on protocol updates, quality improvement projects, and compliance documentation, including training records, TB testing, and Nurse Aide Registry maintenance.
  • Served as Charge Nurse and Weekend Manager on Duty, supervising staff performance, managing patient care delivery, and supporting operational needs across the facility.
  • Served as a resource for clinical information updates related to best practices, regulatory changes, or advancements in nursing techniques.
  • Organized ongoing professional development opportunities such as seminars and guest lectures to expose staff members to emerging trends in healthcare practice.
  • Assisted in the development of annual budgets for educational programs while optimizing available resources towards delivering high-quality training experiences.
  • Delivered targeted coaching sessions to underperforming staff members, enabling them to meet performance expectations within set time frames.

MDS Coordinator - LPN

TriCounty Extended Care Center
04.2002 - 08.2004
  • Completed quarterly and significant change MDS assessments for 75+ residents in skilled nursing, long-term, and memory care units, ensuring timely and accurate submissions aligned with CMS guidelines and regulatory requirements.
  • Led the development, implementation, and review of individualized care plans in collaboration with interdisciplinary teams (IDT), including nursing, therapy, dietary, social services, and activities.
  • Conducted comprehensive resident assessments to identify clinical, psychosocial, and functional needs; translated findings into measurable goals and interventions aimed at maximizing resident outcomes and quality of life.
  • Maintained a Case Mix Index (CMI) above 2.0 for eight consecutive quarters by applying precise ICD-10 coding and optimizing clinical documentation to reflect accurate acuity levels.
  • Facilitated and led weekly and quarterly care plan meetings, actively involving families and residents in goal setting and ensuring plans reflected person-centered care priorities.
  • Championed preventive care initiatives, including fall prevention and pressure injury reduction strategies, resulting in deficiency-free care planning audits.
  • Served as Charge Nurse and Unit Nurse during staffing shortages, managing wound care, admissions, discharges, medication administration, shift reports, and direct communication with providers and family members.
  • Supervised CNA and LPN staff, ensuring daily care delivery aligned with established care plans, facility policies, and regulatory expectations.
  • Administered treatments, tracked resident responses, and ensured ongoing care plan updates based on condition changes, therapy notes, or interdisciplinary input.
  • Played a central role in survey readiness and regulatory compliance, maintaining meticulous documentation and supporting successful state and federal inspections.
  • Set schedules for staff to start and complete MDS assessments and care plan meetings.
  • Ensured timely completion of all MDS assessments, maintaining full compliance with federal and state regulations.
  • Maintained up-to-date knowledge on CMS guidelines and changes to ensure accuracy in reporting and reimbursement processes.
  • Collaborated closely with therapy departments to accurately capture rehabilitation needs within MDS documentation, supporting appropriate resource allocation for residents'' needs.
  • Enhanced patient care quality by implementing comprehensive MDS assessments and care plans.
  • Provided ongoing education for nursing staff regarding MDS best practices, contributing to a knowledgeable and skilled workforce.

LPN Charge Nurse

TriCounty Extended Care Center
03.2001 - 04.2002
  • Served as charge nurse, caring for patients with serious illnesses.
  • Documented vitals and medical histories in patient charts when assessing patients and communicated patient information to physicians and other nurses for care continuity.
  • Provided compassionate end-of-life care, supporting patients and their families through difficult times.
  • Promoted patient independence by teaching self-care skills and explaining conditions and medications.
  • Analyzed patient assessments and laboratory data to bring any issues to attention of physicians.
  • Maintained accurate medical records in accordance with established protocols, ensuring confidentiality of sensitive information at all times.
  • Implemented evidence-based nursing practices to improve patient health and maintain compliance with regulatory standards.
  • Managed daily staff assignments and patient scheduling to guarantee clinic coverage and flow.
  • Coordinated timely admissions, transfers, and discharges for efficient bed utilization within the nursing unit.
  • Provided diagnosis information, treatment possibilities, disease management tips and wound care advice to patients, loved ones and caregivers.
  • Developed and implemented individualized patient care plans.
  • Evaluated patient histories, complaints, and current symptoms.
  • Worked with multidisciplinary team to carry out successful treatment plans for diverse acute and chronic conditions.

Education

High School Diploma -

Hamilton High School
Hamilton, Oh
01-2005

LPN Diploma - License Practical Nursing

D. Russel Lee Career Center
Hamilton,Ohio
11-2000

Skills

  • Prior Authorization (Medicaid/Medicare/Duals) *
  • Utilization Review / Concurrent Review
  • Prior Auth - Meds/Ancillary/Inpatient & Outpatient Services, DME, Chemotherapy, out of network
  • Appeals & Grievances Handling
  • MDS Coordination / Case Mix Index (CMI) Oversight / Care-planning
  • High-Risk Case Management (Oncology, OB)
  • CMS / HIPAA / HEDIS Compliance
  • EMR Systems: Epic, Allscripts, MMIS, MCG, InterQual
  • Claims Resolution/ Submission/ Follow-up
  • High Complex Claims Denials
  • Clinical Staff Training and Supervision
  • Telehealth / Triage
  • Strong work ethic
  • Effective multitasking
  • Professional telephone etiquette
  • Conflict resolution
  • HIPAA compliance
  • Clinical assessment
  • Healthcare software proficiency
  • Chronic disease management
  • Telephonic triage
  • Remote patient monitoring
  • Relational database management
  • Time management
  • Problem-solving abilities
  • Utilization review
  • Healthcare regulations
  • Medical billing/coding
  • Task prioritization
  • Patient condition monitoring
  • Analytical thinking
  • Quality improvement
  • Patient referrals
  • Workflow management
  • Insurance procedures
  • Pharmacy benefit management
  • Patient confidentiality compliance
  • Records maintenance
  • Medical necessity review
  • Quarterly reviews
  • Document review and approval
  • Medical report preparation
  • Review cases

Timeline

Private Duty Nurse for Family Member

(self Employed)
01.2021 - 02.2025

LPN Office Nurse /Medical Office Manager

Ashok Kejriwal, MD
08.2016 - 12.2020

Prior Authorization Supervisor – Medicaid/Medicare Specialist

Centene Corporation - Sunshine State Health Plan
08.2012 - 10.2015

Prior Authorization Nurse / Case Management Nurse

Centene Corporation - Buckeye Community Health Plan / Sunshine State Health Plan
07.2010 - 08.2012

Appeals and Denials LPN

Amerigroup Community Health Plan
04.2005 - 07.2010

Staff Development Nurse

The Meadows
08.2004 - 01.2005

MDS Coordinator - LPN

TriCounty Extended Care Center
04.2002 - 08.2004

LPN Charge Nurse

TriCounty Extended Care Center
03.2001 - 04.2002

High School Diploma -

Hamilton High School

LPN Diploma - License Practical Nursing

D. Russel Lee Career Center

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