Experience

• 

  St. luke's episcopal health system

  May 1984 - Feb 2005

  Intensive care staff nurse

  Staff nurse in a med-surg intensive care unit. Charge nurse responsibilities, preceptor of new staff and resource nurse to the more novice nurse.

• 

  St. luke's episcopal hospital

  Feb 2005 - Jan 2009

  Clinical documetation improvement specialist

  •Responsible for concurrent audit review of physician documentation in patient records; ensuring themost accurate documentation of diagnoses is present for billing and coding purposes and for capturing the patient’s severity of illness.•Responsible for formulation of non-leading physician queries•Performed statistical analysis of data with analyst group to discover areas for improvement of physician documentation and analyst queries•Trained and oriented new staff to documentation analyst role•Served as resource to novice analyst.•Collaborated with other departments for areas analyst could assist for other areas of quality documentation in patient’s records; such as, documentation for core measures.•Collaborated with coders as coding rules change and more clarification was needed from physicians to code record.•Ensured most accurate utilization profiling of patients occurred by working with Case Managers to ensure clinically complex patients were assigned to higher weighted MS- DRGs; additionally, ensuring specificity in documentation to prevent clinical denials due to lack of medical necessity.•Worked in tandem with the Quality Management department to ensure documentation for core measures and Medicare “hospital acquired conditions” were well documented as well as whether they were present on admission. Show less

• 

  Mir fox and rodriguez, pc (mfr,pc

  Jan 2009 - May 2011

  Lead claims analyst

  •Performed Medicare ZPIC post payment compliance audits on provider’s of the Medicare program, which have been identified to have a high potential for Medicare fraud, abuse or waste within the Medicare program part A, B, DME and Home Health. •Performed numerous Medicare Part A medical reviews for one day hospital stay appropriateness, which resulted in substantial overpayments.•Performed numerous Medicare Part B reviews with recovery of substantial overpayments. The reviews consisted of a line by line / code by code review of each service submitted by the provider. Reviewing all three levels of HCPCS/CPT codes.•Analyzed documentation content as it compared to necessary rules and guidelines.•Identified coding errors and provider’s patterns of coding; including up-coding, unbundling and under-coding•Identified the medical necessity of the services billed were met using InterQual criteria for review of inpatient hospital reviews to evaluate level of care.•Summarized review findings; which included, summarization of specific identified errors in the review, the error rate, the overview of findings, and a calculation of the overpayment made by Medicare. Show less

• 

  St. luke's episcopal hospital sugar land

  Dec 2010 - Feb 2012

  Nurse auditor

  •Performed audits on government and managed care accounts that had not been paid according to their contractual agreement because of denied charges; compared charges with clinical documentation to determine the validity of the denial and/or identify any charge discrepancies; documented audit findings; posted adjustments to accounts and forwarded to appropriate units, individuals or organizations for rebilling and/or payment correction as necessary.•Ensured most accurate utilization profiling of patients occurred by working with Case Managers to ensure compliant admission criteria and documentation; additionally, ensuring specificity in documentation to prevent clinical denials due to lack of medical necessity.•Reduced denials of emergency department procedures and test, by providing educational presentations for emergency department physicians about documentation improvement and medical necessity issues.•Performed charge audits as requested by patients; reviewed billed charges for patients who are disputing charges by comparing the charges against all necessary clinical documentation and looking for discrepancies; documents audit results; posted adjustments to accounts and sends to appropriate units for rebilling if necessary. Met regularly with hospital departments to discuss audit statistics.•Performed audits on paid managed care accounts where an external auditor has identified discrepancies(defense audits); reviewed charges originally billed to the payer against the necessary clinical documentation to identify any possible under/over charges; documents and forwarded audit results to payor organizations, external auditors, for review and resolution as applicable; maintained communication with auditors and other relevant individuals/organizations until all discrepancies are resolved.•Met annually with Director of the Health Systems Charge Master to review changes. Show less

• 

  Maxim healthcare services

  Feb 2012 - May 2012

  Clinical documentation improvement specialist consultant

  •CDI Specialist Consultant in hospitals and physician offices throughout the US; providing Clinical Documentation Improvement expertise to various clients, while compiling and analyzing data that will facilitate client adoption of CDI process change and leading to increase quality and consistency of patient outcomes.•Builds and cultivates client relationships with clinical staff while expanding the Maxim Healthcare brand.•Performs CDI implementation activities based on assessment criteria on day to day basis, integrating with other members of the consulting team.•Delivers a quality work product within established timeframes.•Maintains detailed work-paper record of assumptions, methodologies, information sources and final decisions determined during the performance of all implementation tasks.•Assessment and Retrospective audit of a large Medicare Advantage Plan clinical documentation methodologies and processes in relation to HCC validation. Assessment for opportunities for documentation improvement, coding errors and validation of HCC in comparison to the patient’s documented clinical condition. Recommendation for changes in workflow processes, coding, and clinical documentation to capture more accurate HCCs while increasing Risk Scores. Show less

• 

  Medpartners

  May 2012 - Sept 2012

  Clinical documentation improvement specialist consultant
• 

  The claro group

  Sept 2012 - now

  Cdis manager
• 

  Claro healthcare, llc

  Aug 2017 - now

  Senior Manager

  • Senior Vice President

    Jan 2023 - now

  • Director

    Aug 2021 - now

  • Senior Manager

    Aug 2018 - now

  • Manager

    Aug 2017 - now