Quality Improvement Nurse

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Remote Quality Improvement Nurse

  • Carolyn Sessoms
  • 46
  • Resume can be attached- however here is a brief history-Elevance Health, Performance Improvement Enhancement Auditor November 2015 - April 2025 3350 Peachtree Road N.E., Atlanta, Georgia, 30326 Manager: Jennifer Gilbert-Huber • Analyze medical records using nursing knowledge and auditing skills to ensure compliance with regulations and identify areas for improvement in patient care and billing accuracy. • Perform medical record analysis for completeness, accuracy, and regulatory compliance. • Review coding and billing procedures for accuracy and consistency. • Conduct audits to identify potential issues with patient care, documentation, excessive member denials, and billing practices. • Work with healthcare providers, staff, and external auditors to resolve issues and ensure compliance. • Use Milliman Care Guidelines (MCG) to evaluate the medical necessity and appropriateness of proposed and ongoing treatments. • Utilize Tableau, SharePoint, Excel, Microsoft SPARK, and Microsoft Teams for audit tools, notifications, messaging, and data storage. • Familiarity with auditing methodologies, regulatory requirements, AUMSI, and NCQA compliance standards. • Recognized for ability to communicate effectively with healthcare providers, staff, offshore, and external parties. Anthem Inc. (Elevance Health), Nurse Medical Management Senior - Pre-Certification Nurse August 2014 - August 2015 3350 Peachtree Road N.E., Atlanta, Georgia, 30326 Manager: Sandra R. Walker, RN, MSN | 804-512-9465 • Evaluate the medical necessity and quality of healthcare services for SHBP members, ensuring adherence to guidelines. • Review upcoming services based on Anthem’s clinical guidelines, Medical Policies, and Federal Mandates. • Utilize Milliman Care Guidelines (MCG) to evaluate the medical necessity and appropriateness of treatments. • Participate in quality improvement initiatives to enhance clinical review process efficiency and effectiveness. • Collaborate with healthcare providers to gather additional information when needed. • Draft letters to members that outlined benefits and other considerations. • Work with medical directors and care team to review claims, reconsiderations, and appeals, providing expert guidance.
  • Full-time
  • 315 Thistlewood Run
  • Georgia
  • March 31, 2025
  • 601-435-5885
  • carolynsessoms@gmail.com