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Tallahassee, FL 32399
40 years experience W2
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Over 20 years of nursing experience in utilization review, clinical appeals, critical care, public health, and quality assurance.

Information Technology
Dec 2016 - present
Frisco, TX
Performs retrospective medical necessity reviews to determine appellate potential of clinical disputes or denials
  • Performs a comprehensive clinical evaluation for medical necessity and utilization review for appropriate care and services
  • Uses clinical nursing knowledge and critical thinking to determine medical necessity independently
  • Constructs and documents a fact based clinical appeal
  • Reviews the medical record, researches other supporting documents and uses clinical expertise to prepare first and second level appeals
  • Performs feedback to clients
  • Demonstrates proficiency in utilization of electronic tools including InterQual, VI web, HPF medical record, authorization log, and Microsoft office.
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Jan 2007 - Jan 2016
Responsible for coordinating and monitoring the medical appeals process for revenue recovery
  • Responsible for job descriptions and orientation of new nurse auditors.
  • Responsible for performing and directing retrospective reviews and the medical appeal process.
  • Responsible for DRG reviews with supportive rationale for the correct DRG documented, Implemented and directed the Medicaid review using a web based electronic review system as below.
  • Performed retrospective Medicaid reviews for Inpatient Medical and Surgical Services using the eQHealth Solutions (eQHealth)
  • Florida division a web based electronic review request submission system for inpatient providers.
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Medical Devices
Sep 2010 - Sep 2010
assigned hospitals in the areas of the prospective payment system for Medicare and Medicaid Knowledge of Medicare/Medicaid guidelines
  • Chart auditing for the implementation monitoring and quality of patient care Responsible for reviewing medical records for validity of diagnostic information Reviewed for coding/DRG accuracy cost and length of stay outlier audits
  • Reviewed for appropriateness of admission and discharge completeness adequacy and quality of care
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Real Estate Developer
Information Technology
Jan 2001 - Jan 2007
Director, Utilization Management 1991
  • 1995 Panama City, FL
  • Responsible for supervising and coordinating all utilization review and discharge planning/social service functions
  • Supervised the data collection process of medical staff quality assurance Responsible for coordinating and writing all appeals to the peer review organization
  • Responsible for coordinating insurance reviews
  • Responsible to meet the needs of the hospital and Medical staff to ensure compliance with the prospective payment system regulations
  • Responsible for the implementation and coordination of the case management program
  • Knowledge of Medicare/Medicaid guidelines
  • Chart auditing for implementation, monitoring, and quality of patient care *
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Staff RN
Medical Devices
Jan 1983 - Jan 1988
Panama City, FL
Responsible for treating a client caseload of acute and/or chronic health problems including a high incidence of tuberculosis hypertension diabetes and sexually transmitted disease within a generalized public health program.
  • Rural health clinic nurse providing immunizations and healthcare to an underprivileged and isolated rural community.
  • Performed public health care nursing to high-risk mothers and infants in a low-income urban setting for improved pregnancy outcomes. Performed clinical rotation duties family planning immunization and well baby clinic
Diabetes Nursing Registered Nurse
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Non-cloudteam Skill
University of South Alabama
Registered Nurse