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Yyyyyy x. yyyyyy
11686 Jacob Lois CT ö Xxxxxx, XXXXXX xxxxxx ö xxx-xxx-xxxx ö abc@xyz.com
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
Education and Affiliations
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
Professional History
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.
Additional Related Positions
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
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