Licensed Practical Nurse
Open To Work
Tina Lowe
Apex Health Solutions
Columbia,MO
Work Preference
Work Type
Full Time
Location Preference
Remote
Important To Me
Work from home optionHealthcare benefitsWork-life balance
22
years of professional experience
Experienced healthcare professional with strong emphasis on patient care and clinical skills. Proven ability to work collaboratively within multidisciplinary teams, adapting to changing situations with ease. Excels in communication, empathy, and problem-solving to achieve optimal patient outcomes. Reliable and results-driven, with a focus on delivering high-quality care and maintaining positive, supportive environment.
Work History
Appeals and Grievances Nurse
3 Years 2 Months- Investigate and process medical necessity and benefit coverage Medicare Advantage and Commercial appeals, claims, and complaints from members and providers.
- Triage expedited and standard appeals to ensure compliance with State and Federal regulatory requirements.
- Review clinical documentation to apply appropriate clinical criteria and policies in line with State and Federal regulatory requirements.
- Exhibit sound judgment in making independent clinical decisions based on established criteria, guidelines, and protocols.
- Consistently meet performance timeframes while resolving complex and sensitive member issues with high-quality work.
- Initiate Independent Review Entity external reviews and respond to CMS insurance inquiries.
- Participate in Administrative Law Judge hearings.
- Memorial Hermann Health Plan
Senior Appeals Clinical Quality Auditor
1 Year 3 Months- Reviewed denied Medicare Advantage appeal cases for internal Medical Director evaluation, ensuring accuracy and compliance.
- Triaged expedited and standard denied appeal cases to meet State and Federal regulatory standards, facilitating timely resolutions.
- Audited Medicare Advantage Clinical Appeal Agency Packets before submission to Independent Review Entity, enhancing review process efficiency.
- Ensured that services were within the benefit plan and appropriate contracted providers were utilized.
- Identified appropriate clinical setting for services requested.
- Wellcare Medicare
Clinical Appeals Review Nurse
4 Years 9 Months- Reviewed outpatient and inpatient Medicaid appeal and claim requests for medical necessity, ensuring compliance with regulatory standards.
- Collected and analyzed medical information to determine necessity of services based on specific medical criteria, facilitating appropriate care decisions.
- Identified clinical settings suitable for requested services, aligning with benefit plan guidelines.
- Assessed patient needs to identify appropriate clinical settings for requested services.
Prior Authorization Outpatient Care Nurse
13 Years- Reviewed and collected medical information to determine medical necessity of Medicaid services, applying specific medical criteria to support patient care.
- Ensured services complied with benefit plan while coordinating with appropriate contracted providers to optimize patient access.
- Identified suitable clinical settings for requested services, facilitating timely and appropriate patient care.
Education
GPN - Nursing
Skills
Appeals
Prior Authorization
Clinical assessment
Clinical judgment
Clinical documentation
Documentation review
Policy compliance
HIPAA compliance
InterQual Guidelines
Medicaid
Medicare
References
- Megan Reuter, Apex Health Solutions, Manager, Grievance and Appeals, megan.reuter@apex4health.com, (660) 537-1821
- Leslie Chiles, Elevance Health - Healthy Blue Missouri, Director Healthcare Management, lesliechiles@socket.net, (573) 338-5678
- Kelley Peters, Centene Corporation, Senior Director, Care Management, kelleypetersrn@gmail.com, (816) 804-0386
Timeline
Appeals and Grievances Nurse
Apex Health Solutions
08.2023 - CurrentRead More
Senior Appeals Clinical Quality Auditor
Centene Corporation
05.2022 - 08.2023Read More
Clinical Appeals Review Nurse
Missouri Care Health Plan
08.2017 - 05.2022Read More
Prior Authorization Outpatient Care Nurse
Missouri Care Health Plan
08.2004 - 08.2017Read More
Kirksville Area Technical Center
GPN from Nursing
Read More