Martha Carr

• Review SNF member's clinical records to ensure compliance with Models of Care (MOC) and payor guidelines
• Confirm accurate documentation for multiple data points (required Health Maintenance screenings, Code Status, decision making capacity, Advanced Care plan).
• Determine if appropriate referrals were made in a timely fashion when a need was identified.
• Determine if appropriate communication to PCP/POA was made regarding change in status or need is identified.
• Identify clinicians who failed to meet documentation criteria be referred to managers for training/re-education.
• Reviewed over 500 charts per month with an error rate of less than 0.05%.
• Complete monthly Inter-rater Reliability review to accuracy.
• Collaborated with peer to create training materials for HouseCall visits. Trained new staff practitioners house face to face on expectations, how to use to use provided documentation tools for their visits. Seek to identify gaps in care and make referrals.
• Collaborated on Clinical Help line as a Resource for field personnel for unusual situations or documentation questions.

• Reviewed practitioner and hospital records and billing to determine if an appropriate ICD-9 code was applied given the documentation.
• Ensure Medicare and Medicaid Guidelines were met to allow reimbursement.
• Review trends with Data Analyst to determine if there was the possibility for Medicare Fraud, Waste or Abuse for further investigation by federal authorities.
• Complete on site visits to locate additional records and determine if the billed services could have been done at that location. For example a sofa bed in the employee lounge was not appropriate for Sleep Studies.
• Meet with FBI and CMS leadership to make referrals and update them on current cases.

• Litigation support and medical record review for all cases.
• Provided valuable input during pre-trial conferences based on a deep understanding of both medical terminology and legal processes.
• Increased the likelihood of positive case resolution through prompt identification of potential areas for settlement negotiations or alternative dispute resolution strategies.
• Enhanced attorney understanding of complex medical issues by creating clear and concise reports detailing case analysis findings.
• Reduced workload for legal team members by taking on tasks such as conducting medical literature reviews and analyzing health insurance claims data.
• Assisted in trial preparation activities, including drafting deposition questions and preparing exhibits that clearly demonstrated key points in the case.
• Continually expanded professional network within the healthcare community to stay informed about industry trends and developments impacting legal nurse consulting work.
• Utilized strong communication skills to liaise between legal professionals, patients, family members, and healthcare providers throughout the duration of cases.
• Identify medical providers and fact witnesses for interview or subpoena.
• Identify, interview and retain medical experts for chart review and potential trial witness.

Medical Record reviews utilizing Hedis Hybrid Measures as contracted by health care plan.

Position limited to Hedis Review time frame.