kathy

K A T H R Y N J R I L E Y R N , B S N 1 7 3 8 B E S S E M E R S T I R O N T O N , O H I O 4 5 6 3 8

7 4 0 - 6 4 6 - 0 6 9 7

K A T H Y . R I L E Y @ R O C K E T M A I L . C O M

SUMMARY

BSN with experience in healthcare, RAC program, and the regulatory issues facing healthcare.

KEY QUALIFICATIONS

♦ RAC coordinator from initial request through final adjustment/appeal

♦ Extensive experience with all levels of audits and appeal related to Medicare

♦ Third party denials manager including Medicaid MCOs

♦ Charge Master Coordinator including CPT code assignment and OPPS/IPPS changes

♦ Licensed for nursing in the state of Kentucky

EXPERIENCE

2002 to Current: Our Lady of Bellefonte Hospital

Revenue Integrity

♦ RAC Coordinator, Pre-Payment Probe Coordinator, Charge Master Coordinator and CERTs Coordinator

♦ Manages denials for both governmental and commercial payers

♦ Assists in third party audits and coordinates CDM audits and follows through all levels through completion.

♦ Utilizes Xactimed bill scrubber for various denials, CCI, MUE , and LCD edits

♦ Works with keeping all LCD’s up to date and provides education regarding LCD changes.

♦ Monitors all infusion therapy charges to make sure accurate and compliant.

♦ Completed “Medicare Boot Camp” in Nashville TN in October, 2014

♦ Instrumental in installation of Epic software electronic medical record

♦ Extensive understanding of hospital bill types (12X, 13X, 14X, 11X) as well as the coding and billing rules involved with these various bill types.

♦ Works extensively with Care Management in follow up of appropriate status to ensure appropriate use of condition code 44 as well as appropriate use of observation status.

♦ Watches claims for appropriate payments and adjustments as well as follows EOBs for appropriate payment

♦ Member of Corporate Denials Team, which works to ensure appropriate reimbursement for services rendered

♦ Responsible for ensure Medicare A/B rebilling is accurate and compliant

♦ Member of the Billing Coding and Compliance Committee

1997-2003: Our Lady of Bellefonte Hospital

Case Manager

♦ Responsible for discharge planning and utilization review for multiple units

♦ Retro authorizations

♦ Clinical Documentation Program-Certification by JA Thomas 1998

♦ Certified Case Manager 2002-2012

1991-1997 Our Lady of Bellefonte Hospital

Patient Care RN

♦ Cardio-pulmonary Unit

♦ BLS instructor

♦ ACLS certified

EDUCATION

2007– Shawnee State University Portsmouth, Ohio

♦ BSN

1991-Shawnee State University Portsmouth, Ohio

♦ Associate Degree Nursing

1 7 3 8 B E S S E M E R S T I R O N T O N , O H I O 4 5 6 3 8 ( 7 4 0 - 6 4 6 - 0 6 9 7 )