Keep in touch with meI'm using Intch to connect with new people. Use this link to open chat with me via Intch app
Work Background
Virtual Business Office Associates HIAVBO (Health Industry Advisory)Clinical Denials Auditor
Mar. 2025 - Oct. 2025Remote
Virtual Business Office AssociatesClinical Denials Auditor
Mar. 2025Remote
Conifer Health SolutionsAppeal Nurse/Revenue Cycle Appellate Clinician
Oct. 2023 - Feb. 2025* Responsible for recovering revenue associated with disputed/denied clinical claims, preparing and documenting appeals based on industry accepted criteria.
* Performs retrospective medical necessity reviews to determine appellate potential of clinical disputes/denials or those eligible for clinical review.
* Demonstrates proficiency in use of medical necessity criteria sets, including InterQual and MCG Guidelines. Constructs and documents fact based clinical cases to support appeals. * Demonstrates excellent written, verbal and professional letter writing skills.
* Conducts research regarding State/Federal appellate guidelines and applicable regulatory processes related to the appellate process. * Demonstrates knowledge of managed care contracts including reimbursement matrixes and terms.
AmerisourceBergenNurse Educator
Jul. 2013 - Jul. 2023* Provided telephonic consumer support, clinical product and diagnosis related information and services to patients, family members/caregivers and health professionals in a call center environment. * Provided disease process and drug support education. * Delivered emotional support to patients and caregivers. * Worked across functional teams with ability to understand key principles of reimbursement, patient financial assistance, and copay assistance. * Contacted insurance providers and specialty pharmacies to obtain verification of benefits and prior authorization status. Contacted health care providers to assist with prior authorizations and appeals. * Risk assessed patients for compliance and adherence to treatment regimen identifying barriers to care and referring to additional support services.
* Entered all consumer activities accurately in clinical database. * Reported adverse events as directed. * Trained new nurses. * Participated in quality improvement and team training, including productivity, benefit verification process, HIPAA guidelines and documentation.
Bradley Consulting & Management, Inc.TELEPHONIC CASE MANAGER/FIELD CASE MANAGER
May. 2012 - May. 2013Zionsville, Indiana, United States* Performed utilization management of inpatient care using InterQual Guidelines. * Reviewed emergent admissions within one working day of patient admission. Collaborated with off-site and on-site representatives of third-party payers by providing clinical information to ensure payment for hospital stay and post-hospital discharge planning. * Provided education to UK Healthcare physicians and hospital staff regarding third party payer requirements and correct assignment of admission. Conferred directly with physicians to obtain information for admission status, identification of core measures, or present on admission diagnoses.
University of Kentucky HealthcareUtilization Management Nurse
Oct. 2010 - Oct. 2012Lexington, KY* Performed utilization management of inpatient care using InterQual Guidelines. * Reviewed emergent admissions within one working day of patient admission. Collaborated with off-site and on-site representatives of third-party payers by providing clinical information to ensure payment for hospital stay and post-hospital discharge planning. * Provided education to UK Healthcare physicians and hospital staff regarding third party payer requirements and correct assignment of admission. Conferred directly with physicians to obtain information for admission status, identification of core measures, or present on admission diagnoses.
TriHealthDisability Case Manager/Condition Management Nurse
Apr. 2009 - Sep. 2010Lexington, KY* Worked with GE Aviation employees diagnosed with chronic and/or serious medical conditions and provided patient education regarding their medical diagnoses. * Coordinated their medical care to ensure treatment was appropriate for their conditions. * Provided all available resources through their health insurance, employee benefits, and community resources. * Provided medical management of short-term disability and Worker’s Compensation for GE Aviation employees nationwide. Followed their medical treatment, coordinated their care and worked with the treating providers with the goal of facilitating wellness and return to work.
Team HealthFMLA Coordinator
Oct. 2005 - Aug. 2010Madisonville, KY and Albuquerque, NM* Provided medical management and FMLA services for GE Aviation (Madisonville, KY and Albuquerque, NM). * Reviewed employee requests and medical certification for Family and Medical Leave and determined eligibility based on The Family and Medical Leave Act. * Monitored use of Family Medical Leave and continued eligibility of approved cases based on the number of hours worked and FML time used. * Provided FMLA information and education to supervisors and employees.
AXIS Medical ManagementUTILIZATION REVIEW NURSE/ MANAGER
Apr. 2001 - Oct. 2015LEXINGTON, KYSelf Employed/Subcontract with AXIS, a medical management company that specializes in Worker’s Compensation claims. * Reviewed the medical necessity and appropriateness of medical treatment based on Milliman & Robertson Guidelines, Official Disability Guidelines (ODG), and Medical Disability • Reviewed the medical necessity and appropriateness of medical treatment based on Milliman & Robertson Guidelines and Medical Disability Guidelines. Worked closely with Physician Reviewers to guide the claimants’ medical treatment and appropriateness of care. * Performed medical management of catastrophic and acute care injuries in a cost-effective manner. * Negotiated fees with providers and completed bill audits as needed for cost-savings.
Employers Risk ServicesOCCUPATIONAL DISABILITY MANAGER
Apr. 1999 - Apr. 2001LEXINGTON, KY* Provided utilization review services to ensure medical necessity and appropriateness of treatment based on Milliman & Robertson and MDA Guidelines. * Provided case management services to ensure quality treatment, which was reasonable, necessary and cost effective, while ensuring the safe and timely return of the injured worker to his employment. * Monitored medical costs and negotiated pricing. * Ensured stated mandated guidelines, including case management, utilization review and bill audits were followed.
MEDICAL REVIEW SPECIALISTSLegal Nurse Consultant/Medical Review Specialist (Owner)
May. 1998 - Oct. 2015LEXINGTON, KY* Worked with attorneys, insurance companies, individuals and government agencies providing the following services: analysis and summaries of medical records, chronologies of events, expert witness search, claim evaluations, medical research, identification of standards to care, screenings of potential medical malpractice cases for merit and performing as consultant/educator on medical and psychological aspects of legal cases. * Reviewed medical records and translated medical/nursing terms, diagnoses, and treatment plans for attorneys and clients. * Compiled, analyzed and summarized medical records. Provided advisement on specific cases in regards to appropriateness of medical care.
CHARTER RIDGE BEHAVIORAL HEALTH SYSTEMPRIMARY NURSE II, HOUSE SUPERVISOR
Oct. 1996 - Oct. 2001LEXINGTON, KY* Provided direct patient care of psychiatric patients. * Managed milieu, acted as group leader for organized therapy, and served as active member of multi-disciplinary treatment team. * Interviewed applicants and oriented staff. * Oversaw staff in-services on proper documentation techniques and compliance with standards of care. * Conducted chart audits for JCAHO and Medicaid reviews. * Assisted with developing policy and procedures. * Served on risk management teams and acted as treatment plan systems administrator. * Floated throughout the hospital working as RN on Adult Treatment Unit, Addictive Disease Unit, Extended Care Unit and in the Assessment Office. * Acted as house supervisor assuming overall charge as needed. * Worked in patient assessments, screening patients to determine appropriate level of care needed. * Admitted patient to hospital or made referrals based on level of care needed. * Contacted insurance companies for pre-certifications and to relay clinical information.
Intch is a Professional Networking App for the Future of WorkSee more people like Lesa on Intch
300k+ people
130+ countries
AI matching
Get Intch if you'd like to
368654 people
22
Data Entry
15
Virtual Assistant
15
Owner @ West Volusia Bookkeeping and Tax
41778 people
17
Registered Nurse @ Prime Home Health
16
RN, BSN @ UnityPoint Health
16
RN, BSN - Nurse Manager @ Stanford Health Care