3111 Pine Garden Lane
Atlanta, GA 30339
Job Objective To obtain a responsible position as a Medical Review Nurse where my past work experience will be helpful.
Summary of Qualifications:
- Remarkable experience in acute care case management and medical and utilization review
- Sound knowledge of HIPAA Privacy and Security Rules and CMS security requirements
- Solid understanding of coding principles to include ICD-9, CPT, HCPCS, DRG and RBRVS
- Huge knowledge of billing forms, RA’s, EOB’s and provider billing statements
- Strong organizational and documentation skills
- Excellent Customer Service Orientation
- Strong Interpersonal Skills
- Outstanding ability to maintain high quality work while meeting strict deadlines
Medical Review Nurse, August 2005 – Present
HMS, Atlanta, GA
- Performed pre-certification, concurrent and retrospective review of out-patient and in-patient services.
- Consulted complex cases that did not met established criteria and guidelines with the physician advisor.
- Communicated with hospital staff to ensure timely discharge planning and placement in most appropriate setting.
- Evaluated requests for outpatient services such as home care, therapies and DME.
- Identified high-risk members and initiated appropriate referrals to case management, COB/TPL staff, HCCT, etc.
- Adhered to NHPRI benefit plans and ensured members health care needs are fulfilled.
Medical Review Nurse, May 2000 – July 2005
Coventry Health Care, Atlanta, GA
- Completed medical review form, documented findings, and provided policy and regulatory support for determination.
- Conducted research on relevant State specific billing and reimbursement regulations.
- Assisted in resolving Medicaid related issues.
- Participated in on-site visits to retrieve medical records and conducted provider entrance and exit conference.
- Adhered to department and regulatory standards for accuracy, proficiency and documentation.
- Participated in department continuous quality improvement activities.
Bachelor of Science in Allied Health Science, Centre College, Danville, KY
958 N Conecuh St
Saint Marys, GA 31558
Objective Looking for a challenging role as a Medical Review Nurse in the field of the nursing and caring where my skills and knowledge can be utilized effectively.
- Sound knowledge of the medical terminology, assessments, patient’s evaluation and clinical medicine.
- Strong knowledge of medical terminology and surgical terminology.
- Wide knowledge of the Medicare program.
- Comprehensive knowledge of medical billing and insurance claim filing.
- Broad clinical experience and excellent analytical skills.
Medical Review Nurse, 2004 to till date
Ohio State University Hospital, Columbus, OH
- Performed clinical review of medical records.
- Checked out balances due from insurance companies and sent invoices to insurance companies.
- Entered data electronically to process payments, charges, denials and adjustments.
- Conducted client interviews.
- Maintained internal quality control procedures to ensure the reliability of project reviews.
CPR Certification, 2004
Rush University, Chicago, IL
B.S in Nursing, 2003
Yale School of Nursing, New Haven, CT