Tracey Pierce

• Audited claims for medically appropriate services provided in both inpatient and outpatient settings while applying appropriate medial review guidelines, policies and rules.
• Documented all findings referencing the appropriate policies and rules.
• Followed home health regulatory adherence for(CMS) determining medical necessity for services, and reviewed denied claims for potential appeals
• Extensive experience with OASIS documentation and Health Insurance Prospective Payment System (HIPPS).
• Generated letters articulating audit findings.
• Supported my findings during the appeals process if requested.
• Worked collaboratively with the audit team to identify and obtain approval for particular vulnerabilities and/or cases subject to potential abuse.
• Worked in partnership with clients, CMD colleagues, and other contractors on improving medical policies, provider education, and system edits.
• Kept updated on medical practice, changes in technology, and regulatory issues that may affect clients.
• Collaborated with the team to minimize the number of appeals; Suggest ideas that may improve audit workflows; Assisted with QA functions and training new team members.
• Participated in establishing edit parameter and development of Medical Review Guidelines.
• Cross trained in all clinical departments/areas.
• Experience with utilization management systems or clinical decision-making tools such as Medical Guidelines (MCG) or InterQual.
• Experience with and extensive knowledge of ICD-9, ICD-10, CPT-4 and HCPCS coding.
• Knowledgeable of insurance programs, particularly the coverage and payment rules.
• The ability to maintain high quality work while meeting deadlines.
• Excellent written and verbal communication skills.
• Ability to manage multiple tasks including desk audits and claims review.
• Independently able to use standard office computer technology and have experience using a case management system/tools to review and document findings.
• Able to manage multiple assignments effectively, create documentation outlining finding.
• Able to electronic health record systems to track and manage patient information efficiently.
• Provided support in identifying potential areas for process improvement within clinical reviews.
• Assisted in training new staff for clinical documentation review processes.
• Participated in ongoing professional development to increase knowledge of healthcare regulations and policies.
• Reviewed and documented relevant information into data system applications.
• Demonstrated extensive knowledge of medical terminology, pharmacology, anatomy, and physiology while conducting accurate clinical assessment.
• Member of a trusted team by consistently demonstrating professionalism, integrity, and commitment to excellence throughout the clinical review process.
• Managed caseload efficiently while maintaining strict confidentiality of sensitive information per HIPAA regulations.

.