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Appeals And Denial Manager Resume

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PROFESSIONAL SUMMARY:

  • I am experienced as a self - motivated and proactive professional; goal oriented Executive
  • Leader, Clinical Medical Reviewer, and Clinical Documentation Specialist. I am proficient with ver a decade of Case Management and Utilization Review experience in Acute Case
  • Management/DCP/Managed Care, and certification in MS-DRG clinical documentation.
  • I possess management experience in risk and quality management, corporate compliance and
  • HIPAA Privacy Program, as well as Confidential Adjudication and Commercial Insurance Reimbursements.
  • I have been successful with Confidential preparation teams and successful financial recovery.
  • I in corporate the ability of versatility and professionalism as a part of my ethics and business goals.
  • I possess effective managerial skills, communications skills and ability to relate with and train persons of all backgrounds and demographics.
  • I possess a strong team leadership capability, by providing team members with positive reinforcement and motivation for them to excel in their jobs.
  • As a critical thinker, I can conceptualize, analyze, and evaluate situations to make sound constructive decisions.

SKILLS:

Microsoft Office, EPIC, Cerner, Centricity, HMS, EMR, 3M, McKesson, InteQual.

EXPERIENCE:

Confidential

Appeals and Denial Manager

Responsibilities:

  • Manager of Confidential Adjudication and Commercial Insurances Reimbursements. Assured all
  • Commercial payments for denied Confidential ; communication with all payers to correct
  • Payment reimbursements hard abstraction for documentation correction as well Medical Confidential
  • Adjudication. Abstracted information from charts using M/R and Interqual criteria.
  • Collaborated with Physicians coders, CM/UR and administration for the clarity of medical
  • Necessity of patient’s acute hospital stay. Conducted electronic chart review with knowledge of
  • 3M and MS- DRG/P.O.A Query forms. Track and trending /Case Mix index and implantation of
  • CDIS process. Interacted directly with various insurance
  • Companies to review details of denials and assist with needed
  • Information for reversal.

Confidential

Ortho-Surgical Manager

Responsibilities:

  • Case Management, Discharge Planning, and strong working knowledge of Medicare, MedicaidCommercial Reviews and Appeal Process.
  • Interact closely with family and medical staff for concurrent reviews and discharge planning needs.
  • Participated with all members of healthcare team in patient care conference to assure the best patient outcome.
  • Assured all post-acute needs were met.
  • Worked with Epic and All Scripts as well as M/R.

Confidential

Ortho-Surgical Manager

Responsibilities:

  • All Scripts Surgical Manager for Authorization Criteria. Prospective Payment Authorization
  • Review Manager. Worked with Cerner, Interqual and All Scripts. Reviewed overall aspect of
  • Quality of care process, Case Management plans, policies and procedures. Correlated
  • Connection between denials and Case Management, oversaw Utilization, Under Utilization
  • Committee preparation. Managed reimbursement of all payers. Reviewed/revised CSR role in
  • Central Business (ICD-9) coding and correct diagnostic procedure codes for appropriate billing.

Confidential

HMO Case Manager

Responsibilities:

  • Responsible for admissions and authorization upon admission, Continuum of Care, Discharge
  • Planning and Communication with patient and families.
  • Communicated with payers for safe discharge and long term care arrangements.

Confidential

CDI Specialist

Responsibilities:

  • Abstracted information from charts using EMR and Interqual criteria.
  • Collaborated with Physician’s coders, CM/UR and administration for clarity of medical necessity per patient’s acute hospital stay.
  • Electronic chart review with knowledge of 3M and MS-DRG\P.O.A. Queried forms.
  • Tracked and trend Case Mix index and implantation of CDIS process.

Confidential

Utilization Review Consultant

Responsibilities:

  • Documentation and Clinical review. Teamed with Dir. of HIM to establish programs for physician
  • Query record reviews electronic formats to include 3M applications.
  • Assisted with RAC Training
  • Audited and processed Treatment Authorization Request Denials.
  • CDIS Record Review Auditor
  • RAC Coordinator and Meeting Communication Officer.
  • Conducted RAC reports and responses

Confidential

Director of Case Management

Responsibilities:

  • Evaluated patient’s clinical condition and documented need for inpatient acute level of careInterQual process assured that patients are receiving concurrent / retrospective review processConducted grievance and appeals.
  • Evaluated and accessed staff performance evaluations.
  • Performed Interdisciplinary rounds.
  • Identified barriers to discharge, referred all complex high-risk patients to appropriate disciplines for assist. Interacted with hospital medical and auxiliary staff as well as patient family members to assure patient satisfaction and assured that patients were moved appropriately throughout the continuum of care process.

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