Utilization Review, Denial Management, Revenue Analyst Resume

Desired Industry: Healthcare	SpiderID: 2792
Desired Job Location: Duluth, Georgia	Date Posted: 6/7/2005
Type of Position: Full-Time Permanent	Availability Date: 7/11/05
Desired Wage: $60,000
	U.S. Work Authorization: Yes
Job Level: Experienced with over 2 years experience	Willing to Travel: No
Highest Degree Attained: Bachelors	Willing to Relocate: No

Objective:
Pursue a position that will build on my existing business office experience and offer both challenge and opportunity for advanced learning within the health care industry.

Experience:
SUMMARY OF QUALIFICATIONS

Enthusiastic team player, resourceful independent contributor with positive attitude; able to perform a multitude of tasks in an organized and time-efficient manner; good verbal and written communication; strong leadership skills and ability to delegate effectively; excellent analytical skills; fast learner with good knowledge transfer skills.

RELATED EXPERIENCE

2001-present Northside Hospital Atlanta, GA
Nurse Revenue Auditor
� Perform audits of patient accounts for Northside, Northside Cherokee, and Northside Forsyth campuses focusing on revenue discrepancies.
� Calculate and analyze data regarding charge posting errors and duplicate account errors.
� Monitor problem trends and provide department in-services as necessary.
� Analyze and distribute monthly late charge reports for all departments.
� Developed and maintain excel document to track all observation and one day stay accounts to determine correct patient type, correct charges, and ensure accurate billing.
� Developed departments first training manual and participate in training of all new audit specialists. Participate in continuous cross-training of per-diem audit nurses.
� Develop and implement yearly action plan with process improvements for the department.
� Developed departments first Policies and Procedure�s manual.

2001-2001 Scientific Staffing Atlanta, GA
Crawford & Company; Case Manager, State of Washington Team (Temporary Staff)
� Obtained clinical information on patients for outpatient procedures, inpatient admissions, and concurrent reviews for worker compensation accounts.
� Utilized Interqual criteria and other state mandated guidelines to determine appropriate length of stay for hospitalizations.
� Continued to follow patient accounts through rehabilitation program if necessary.
� Worked with board of physicians to obtain approval on cases that did not meet Interqual criteria.

1999-2001 Goodroe Administrative Services Atlanta, GA
Network Clinical Coordinator
� Review preauthorization requests for multiple specialty capitated networks.
� Determine correlation of comprehensive clinical data for determination of medical necessity.
� Calculate and analyze utilization data and preauthorization data.
� Organize and lead Utilization Management/Quality Management programs and meetings.
� Interface with the Board of Directors to identify initiatives to meet program objectives.
� Work with the Committee and Board to develop, revise and implement practice guidelines, and network policies.
� Communicate with Payers to assure compliance with industry standards.
� Evaluate the performance of each provider network and provide comparative data in annual program evaluations.
� Develop educational materials for providers and their office personnel regarding clinical guidelines and criteria for requested procedures, and provide onsite training.
� Develop and implement training curriculum for new preauthorization staff as well as provide ongoing clinical education to the claims department regarding medical appropriateness of urgent/emergent situations.
� Devise marketing strategies to assist with network and company growth.

1998-1999 Unicare / Cost Care Inc. Atlanta, GA
Utilization Review Nurse, State of Georgia Team
� Obtained clinical information on patients for outpatient procedures, in-patient admissions, and concurrent review while screening patients for case management eligibility.
� Researched clinical information on nasal surgeries, penile implants, insulin pumps, and breast reductions/reconstruction, and provided backup support for the Prior Approval Nurse.
� Performed additional duty of case manager, which included researching and negotiating pricing of durable medical equipment while ensuring the medical necessity of those items.
� Mentored new preauthorization nurses.

1997-1999 Saint Joseph�s Hospital Atlanta, GA
Staff Nurse, Renal and Pulmonary Services
� Provided holistic care to 6-8 patients while communicating with additional staff to formulate care plans and discharge needs.
� Employed Medical Information System/TDS and IDX/ Phamis Last Word to obtain current orders, order supplies, chart medications and treatments.
� Served as an IDX computer resource supporting the implementation of the new IDX Computer System.

1996 Mayo Medical Center Rochester, MN
Internship Program Participant, Urology and Vascular Surgery Unit
� Provided holistic care to patients with various national origins and English language proficiency levels under the supervision of a registered nurse.

Education:
EDUCATION
Eugene W. Stetson School of Business at Mercer University Atlanta, GA
Several courses towards a Master of Science in Health Care Management including:
Finance & Accounting, Economics, and Cultural Diversity.

University of Virginia Charlottesville, VA
Bachelor of Science in Nursing with Distinction, May 1997

Affiliations:
COMMUNITY INVOLVEMENT

1999- 2002 Atlanta Junior Chamber of Commerce Atlanta, GA
Vice-President of Community Development, 2001Board of Directors
� Devised an annual plan of action and budget for the community development area, monitor and evaluate outcomes, and draft a three-year plan for this chapter area.
� Coordinated and participated in various Community, Individual Development, and Management programs.
� Recruited and trained new members for project management roles.
� Led and managed a team of people in addressing the developmental needs of our community.
� Utilized various marketing tools for event promotion including contributing to the Atlanta Jaycees monthly Newsletter �The Initiative� and giving presentations to the general membership.
� Served on the Corporate Sponsorship Committee and assisted with fundraising for an International Conference hosted by the Atlanta Junior Chamber of Commerce.

1999 Avon�s Breast Cancer 3-Day Participant
� Independently raised over $2,000 for Breast Cancer Education and Research.

1997 Sigma Theta Tau International Honor Society of Nursing

Skills:
TECHNICAL SKILLS

Windows 2000, Word, Word Perfect, Excel, Act, Access, Outlook, PowerPoint, Interqual, HBOC Star Clinicals and Financials, Horizon Patient and Business Folder, and other various healthcare information systems and the Internet.

Additional Information:
MAJOR ACCOMPLISHMENTS

Professional Licensure in Virginia, Georgia, and North Carolina.
Super Supporter for the Quarter, Atlanta Junior Chamber of Commerce, 1st Quarter 2001.
New Jaycee of the Year for Region 5, Georgia Region 5 Junior Chamber of Commerce, 2000.
Member of the Month, Atlanta Junior Chamber of Commerce, May 2000.
Employee Recognition Award Recipient, Unicare, 1999.
Certified Breast Cancer Education Facilitator, American Cancer Society, 1997.

Reference:
Available upon request

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