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Justin
JFSamiee@gmail.com
305-903-2705
Miami, FL 33158
RN - Appeals Analyst/Denial Prevention
11 years experience W2
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Average rating
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Summary

Computer Skills

  • Advent Health: Cerner, CPA, Experian, Athena, Sunport, HealtheRegistries, Discern reports
  • McKesson InterQual
  • Humana: eCW
  • HCA: Meditech-CPOE
  • Baptist Health Charting: T-system, Net Access
  • Microsoft Office Suite, Windows OS 95/98/2000/NT/XP/Vista/7/10, MS Project, Visio, SQL Server
  • Knowledge of PC Repair & Assembly, Networking, as well as TCP/IP, HTTP, FTP

Softwares/Systems

  • Lotus Notes, ACT!/Salesforce, Business Objects, Adobe Premiere, Adobe Photoshop, Real Producer, Flash, Fireworks, Dreamweaver, Flash Server, QuickBooks, AutoCAD, Norton Ghost, Trackit!, Crystal Reports, Subversion, VMware, Nero, Tandberg IP Conferencing MS

Experience
RN - Appeals Analyst/Denial Prevention
Medical Devices
Mar 2019 - present
  • Evaluate denials and non-certified days from 3rd party payers to determine appropriateness of denial and feasibility of appeal.
  • Reviews surgery cases to ensure appropriate CPT, LOC, Relevant testing, authorization and medical necessity is present in the EMR prior to billing.
  • Clinical resource for pre-access, billing/coding, patient financial services
  • Familiar with CPT, ICD-9 &-10 & DRG coding
EMR Registered Nurse Appeals
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Quality Improvement RN
Dec 2018 - Mar 2019
  • Reviewed charts and abstracted clinical data from various EHR's
  • Identified and closed gaps under ACO\CMS quality measures
  • Assisted with reporting in compliance with initiatives and standards
Compliance Registered Nurse
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Registered Nurse Managed Care / Medical Management
Medical Devices
Jun 2015 - Sep 2018
(Telecommute) / HEALTHNET VA FEDERAL SERVICES Registered Nurse Managed Care / Medical Management Utilization Review Nurse, Care Coordination, Provider Relations
  • Utilized McKesson InterQual Criteria, performing first level clinical reviews for all inpatient and ancillary services requiring authorization.
  • Assisted in requirements gathering for policies and procedures, internal audits, and reporting
  • Completed 20+ discharge calls daily to decrease re-admittance and hospitalization and to ensure post-op care is followed.
  • Performed case management, disease management, and care coordination for veterans between PCCC and non-VA providers.
Post-op Registered Nurse Veterans Affairs Audit Nursing
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Registered Nurse Supervisor - Frontline Leader
Medical Devices
Sep 2013 - Feb 2015
Miami, FL
  • Collaborated with clinicians and administration to provide efficient and effective quality of care.
  • Reviewed actual and proposed medical care and services against NCQA established guidelines.
  • Performed as the HEDIS liaison and implemented quality improvement initiatives in adherence with STAR measures.
  • Assisted billing and coding with clinical charting quality and standards, CPT, and ICD coding.
  • Supervised Medical Assistants as well as non-clinical staff.
  • Participated in the development, implementation, and interpretation of nursing policies and procedures.
Registered Nurse Nursing
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Registered Nurse (Medical Surgical/Telemetry/Orthopedics)
Medical Devices
Aug 2012 - Aug 2013
Aventura, FL
  • Managed patient care while working with physicians, case management, physical therapy, respiratory, nursing aids, monitor techs, and many other disciplines to provide excellent patient outcomes.
  • Assessed patient's condition based upon observation of patient and interview of patient and family, physician's diagnosis and data, diagnostic results, and relevant data from other healthcare providers.
  • Documented all aspects of patient care and maintained patient records, including but not limited to, core measures and patient safety.
  • Provided patients and family members with relevant healthcare education and instructions regarding treatments and procedures including pre-and post-hospital care as appropriate.
Orthopedic Registered Nurse Nursing
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Nurse Scholar Partner
Medical Devices
Jan 2011 - Jul 2012
Miami, FL
  • Program Employee (Emergency Department, Cardiology, Medical surgical)
  • Assisted Emergency Department Nurses in all facets of RN responsibilities: patient management and care and documentation/charting to reflect standards of care.
Cardiology Registered Nurse Nursing
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Edit Skills
Non-cloudteam Skill
Education
secure file server
Florida International University 2003
Management Information Systems
Florida International University
Nursing
Florida International University
projects that created an in-house IPCC
learning center
Certifications
CPA
License Information
Licensed Registered Nurse, Multi-state License
FL License # RN9345474, Exp:
Skills
Registered Nurse
2021
8
Nursing
2018
7
Audit
2018
3
Post-op
2018
3
Veterans Affairs
2018
3
Appeals
2021
1
Cardiology
2012
1
EMR
2021
1
Orthopedic
2013
1
Compliance
2019
1