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Diagnosis Related Group Clinical Validation Auditor-Rn

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Seasoned professional with extensive experience driving positive patient outcomes through comprehensive oversight of the clinical care review process. Demonstrated excellence in developing and administering policies and procedures for utilization control of inpatient and outside referral services countywide; monitoring referral patterns and making recommendations; assisting in development and implementation of procedures to track and trend specialty. Conducted utilization reviews, demonstrating a strong attention to detail and comprehensive understanding of the review process. Registered Nurse (RN) with a wealth of expertise in utilization review and leadership roles within pediatrics, adult medical/surgical, and the health insurance industry. Proficient in reviewing medical necessity for ongoing client care, ensuring appropriate levels of care are provided and connecting clients to higher levels of care when necessary. Skilled in leveraging technology and leading initiatives to effectively manage and achieve key performance indicators (KPIs). Proven track record of identifying data-driven needs and opportunities for enhancing clinical care review processes on a large scale. Successfully led teams of 10-15 staff members, providing guidance, support, and fostering a collaborative work environment.

Dynamic clinical professional with extensive experience at Cotiviti, excelling in complex audits and demonstrating a self-directed work ethic. Proven expertise in ICD-10-CM coding and detail-oriented analysis, consistently exceeding productivity goals while fostering collaborative teamwork to enhance audit efficiency and identify trends for recovery opportunities.

Certified Neonatal Intensive Care Nurse with 20+ years experience specializing in Neonatal Intensive Care Nursing in a level III NICU. Experience includes advanced training in intubation and central line placement, transport, and delivery attendance.

Transition to Clinical Validation Auditing in 2019, applying extensive knowledge and clinical background in Neonatal and Obstetric nursing to ensure documented diagnoses are clinically valid. Analyzes and audits claims by integrating medical chart coding principles, clinical guidelines, and objectivity in the performance of medical audit activities. Identifies potential documentation and coding errors by recognizing aberrant coding and documentation patterns.

A high performing and dynamic provider educator, HCC Coder/auditor with vast experience in Risk Adjustment and Valued Base Care. Possesses expertise in leading coders, providers and medical staff achieve overall better health outcomes. Possesses expertise documentation standards and guidelines, review medical records for physician documentation integrity and improvement, educate and give feedback for providers and coders to achieve correct documentation, reporting the highest specificity of a patient's diagnosis and reporting the most accurate and complete patient assessment and achieving the correct RAF scores. Leading providers and provider practices to overall better workflows, leading to the best patient outcomes.

Bonnie Lewis, RN

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Auditor, Clinical Validation

Audit and Appeals Coordinator

Utilization Management RN

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Associate of Science - Nursing

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Auditor, Clinical Validation

Audit and Appeals Coordinator

Utilization Management RN

Associate of Science - Nursing

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