Dynamic, ambitious and highly knowledgeable Medical Industry Compliance Specialist, eager to contribute superior medical coding, strong knowledge of Medicare regulations and certification requirements toward supporting the objectives of a progressive medical industry organization. 

 

Core competencies include:

 

   Project Management/Program Development

   Extensive Knowledge of Medicare A and B

   Collaborate in a Team Environment

   20+ Years of Nursing Experience

   Certified Professional Coder

   Compliance Requirements

   Superior Communication Skills

   CPT-4 and ICD-9 Codes

   Strong Research and Analysis

   Solid Leadership Abilities

 

 

University of South Carolina, Columbia, South Carolina - Bachelor of Science, Nursing               

Medical-Legal Institute, INC, Houston, Texas - Legal Nurse Certification, 2002                                                                  

HRAI Coding Specialists, LLC, Glenn Allen, Virginia - Certified  Professional Coder, 2004

Member, American Academy of Professional Coders

               

 

First Coast Service Options,  Xxxxxx, XXXXXX                                                                                 2002 to Present

Senior Health Services Analyst

   Spearheaded project management initiatives to evaluate and revise Local Coverage Determinations (LCDs) For Xxxxxx, Puerto Rico, Virgin Islands and Connecticut, resulting in greater clarification of requirements and Medicare guidelines.

   Provide analysis and evaluation of emerging technology and drugs for compliance, investigate device submissions for payment and determine reimbursement levels for drug coverage.

   Collaborate extensive within the Medicare community to maintain current requirements and policies;  ensure consistency and cohesion among Medical Review Guidelines (MRGs), Decision Consistency Memorandums (DCMs) and Standard Operating Procedures (SOPs) for internal users.

   Perform extensive quality audits, evaluate CPT, HCPCS, and ICD-9 codes to determine coverage, and interact with medical society representatives to define policies within their specialties.

   Contributed as an integral team member of problem solving teams, and regarded as a Subject Matter Expert Part A Medicare and  End-Stage Renal Disease topics.                

                                                                               

BlueCross-Blue Shield of Xxxxxx, City, XXXXXX - RN Benefits Safeguard Analyst                           1998 to 2002

   Provide 1st level appeals review for Medicare Part A claims submissions; leveraged superior grasp of Medicare rules and regulations to make determinations on disposition of claims.

   Performed comprehensive review and analysis of data to determine if services provided were in conjunction with Medicare regulations.

   Facilitated training and continuing education forums for Medicare providers to instruct the interpretation of Medicare regulations when providing Part A services to beneficiaries. 

   Integral ISO 9000 team member; contributed to the development of Standard Operating Procedures in accordance with application procedures for certification.

 

 

 

 

Pediatric Services of America, Xxxxxx, XXXXXX - Home Health Nurse                                        1990 to 1997

   Provided hands-on patient care in critical care units in area hospitals, and home health services for chronically ill infants and children.

   Assessed each child s needs for outpatient and nursing services; collaborated with providers to define care plans and treatments, and provided infusion therapy and monitored mechanical ventilators.

 

NMC Homecare, Xxxxxx, XXXXXX - Nurse Clinician                                                                              1996 to 1998

   Performed comprehensive evaluations to make determinations and recommendations for each clients home care needs; developed interventions and care plans to provide the necessary treatment to encourage recovery and adaptation to living with disease progression.

 

Option Care of Xxxxxx, Xxxxxx, XXXXXX - Patient Care Coordinator                                  1993 to 1996

   Directed the coordination and facilitation of infusion therapy for home based clientele.

   Provided direct patients care, acted as liaison between patients, physicians and nursing agencies to maximize treatments within the parameters of insurance coverage.

 

 

Underhill Nursing Services, Xxxxxx, XXXXXX - Staff Relief Nurse                                                  1988 to 1990

Nursefinders, Xxxxxx, XXXXXX - Staff Relief                                                                                               1987 to 1988

Alexian Brothers Hospital, San Jose, CA - RN                                                                                           1984 to 1987

Xxxxxxying Nurses, Brownsville, TX - Traveling Nurse                                                                                     1982 to 1984

Richland County School District, Columbia, SC - Health Care Coordinator                              1978 to 1982

Richland Memorial Hospital, Columbia, SC - Staff/Charge Nurse                                                               1979 to 1982

Medical Training Center, Columbia , SC - Nursing Instructor                                                          1979 to 1980