1. NINA RAM, RN MS
MEDICAL RECORDS REVIEWER
UTILIZATION MANAGEMENT
• Taneytown, MD • Tel 240.446.2726 • Fax 410 756 6962 • Cloud Fax 240-290-1313
• NinaRam1@verizon.net • www.linkedin.com/in/ninaramrnms/
• Consistently delivers robust bottom line results while ensuring the highest levels of quality validation
standards.
• Creative, innovative, and forward thinking - adept at handling complex challenges with thoughtful and
clearly defined strategies that ensure high performance.
• Works effectively in environments of intense pressure requiring high levels of sensitivity and proficiency.
• Adheres to the strictest levels of regulatory compliance, maintaining meticulous documentation and
records.
Core Competencies
• Case Reviewing • Documentation Specialist • Utilization Management
• Quality Assurance Records Management • Regulatory Compliance
Professional Experience
Maryland Physicians Care – AETNA, Linthicum, MD 5/19/14 - present
UM CLINICAL CONSULTANT RN (as a Concurrent Review Nurse)
Focus is on concurrent review in an MCO ORG/Milliman environment. Utilizes clinical skills to coordinate,
document and communicate all aspects of the utilization/benefit management program. Applies critical thinking
and knowledge in clinically appropriate treatment, evidence based care and medical necessity criteria for
appropriate utilization of services.
• Averaging a daily caseload of about 35. However, due to increased member enrollment by mid-2016,
average daily caseload has been averaging low to mid 40s.
• Consistently completing yearly IRR (Inter-Rater Reliability) training, pre-tests, and final tests @ better than
passing scores (85%).
• Most recent 2016 Report Card Evaluation @ 100%, while all since 2014 @ better than passing scores (90%).
• NCQA Accreditation w/Commendation (2016 – my daily contribution in this effort being just a small grain in
a massive Linthicum team effort helping to achieve this success).
• SEC (Service Excellence Committee) Member since 2014 thru mid-2016 (presenting a 2015 PowerPoint
Presentation to the Linthicum MCO team, “The Impact of Sleep on Aging, Overeating, & Longevity:
Reinventing Mid-Life”).
Consults and lends expertise to other internal and external constituents in the coordination and administration of
the utilization/benefit management function
Gathers clinical information and applies the appropriate medical necessity criteria/guideline, policy, procedure
and clinical judgment to render coverage determination/recommendation/discharge planning along the
continuum of care
Utilizes clinical experience and skills in a collaborative process to evaluate and facilitate appropriate healthcare

2. services/benefits for members
Coordinates/Communicates with providers and other parties to facilitate optimal care/treatment
Identifies members who may benefit from care management programs and facilitates referral
Identifies opportunities to promote quality effectiveness of healthcare services and benefit utilization
Johns Hopkins Health Care, Glen Burnie, MD 2/12/14-4/30/14
HEDIS NURSE AUDITOR
Perform assigned medical records abstraction either on-site at provider locations or remotely in support of the
annual HEDIS audit, averaging daily 20-24 chart reviews, with duties to include:
• Application of NCQA structured auditing criteria during medical record reviews to abstract significant data.
• Consistently maintaining a 90% or better accuracy rate in abstracting, documenting, and entering this data.
• Copying documentation from medical records to validate all data abstracted and entered, maintaining strictest
HIPAA confidentiality in a safe, organized manner while auditing and abstracting for regulatory compliance.
APS Healthcare, Mechanicsburg, PA 6/3/13– 8/8/13
UTILIZATION MANAGEMENT RN REVIEWER
Concurrent Reviewer for Today's Options, a Medicare Advantage, Medicare Part C, product, utilizing InterQual
Level of Care Criteria Acute Care guidelines, CMS (Centers for Medicare & Medicaid Services) NCDs and LCDs
(National and Local Coverage Determinations), Medicare Chapter 8, and members' EOCs to bring about managed
care decisions, and participating in the appeals process when necessary. Averaging a daily caseload of about 20.
• Achieved a 100% accuracy and proficiency rating while still in orientation – never achieved previously by any
UM RN employee in this office!
ADVANTA Government Services, Annapolis Junction, MD 3/26/12– 9/15/12
MEDICAL RECORDS REVIEWER (part-time)
Performing retrospective electronic medical chart reviews of Medicare Hospital & HomeHealth cases, following set
CMS benefit guidelines, utilizing the Plan of Care requirements and certification elements, along with data
elements of the UB-04 hardcopy billing, and 837 electronic billing processes. Familiar with the use of InterQual.
Knowledge of the general principles governing reasonable and necessary hospital medical services, and skilled
nurse homehealth services, and applying them to specific situations of services provided, and the corresponding
billing for those services. Familiar with OASIS payment methodology utilizing e-ROVER software, to guide and
support reviewer’s abstraction of electronic medical record documentation. Averaging 3 electronic appeal reviews
per hour.
Additional Experience
• Comprehensive Care Manager (CCM) in Disease Management, Healthways, Columbia, MD
2004-2011
 Proactively pursued cross-training in all products/services across the business to maximize operational
effectiveness and population penetration by averaging 3 completed calls per hour, as one of the few
multi-licensed RNs with patients/members/RN licenses in CA, NV, and MA.
• Senior Utilization Review Nurse, Team Lead, ADP / Integrated Medical Solutions, Rockville, MD 1996-
2003
 Streamlined the inter-office triage medical review process, achieving a review time of 24-48 hours, thereby
exceeding all client contractual obligations.
 Facilitated the maintenance of a 96% production rating and 98% quality rating.
• Utilization Review Clinical Supervisor, Staff Builders, Washington, DC 1994-1995
 Guided the office in successfully achieving the first JCAHO Accreditation with Commendation.
• Director of Clinical Services, Olsten Kimberly Qualitycare, White Plains, NY 1993-1994
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3.  Ensured branch compliance with Licensed Home Care Services Agency guidelines, as defined by New
York State DOH regulations and company standards.
• Patient Care Manager, Westmoreland Hospice, Greensburg, PA 1992-1993
 Developed OSHA Blood-borne Pathogens Standard In-service for the hospice team.
• Home Care Manager, Jacob Perlow Hospice, Beth Israel Medical Center, New York, NY 1990
• Inpatient Unit Manager, Ritter-Scheuer Hospice, Bronx, NY 1987-1990
• Nursing Supervisor / Branch Manager, Staff Builders, Flushing, NY 1985-1987
 Led the branch to receive its first New York State DOH LHCSA license.
• Staff Nurse - Oncology/Bone Marrow Transplants, Montefiore Medical Center, Bronx, NY & Yonkers General
Hospital, Yonkers, NY 1983-1985
Education & Professional Development
Health Information Technology, AA Degree in Allied Health Sciences, Carroll Community College, Westminster, MD
Master of Science, RN / FNP, Pace University, Lienhard School of Nursing Graduate Division, Pleasantville, NY
Bachelor of Science, Biology / Pre-Medicine, Roanoke College, Salem, VA
LICENSES / CERTIFICATIONS
(RN) Licenses: NY by examination (NCLEX 1981) – inactive; MD and PA by endorsement – active
PROFESSIONAL ORGANIZATIONS / AFFILIATIONS
Phi Theta Kappa National Honor Society (2014 – onward)
CPUR, CPUM – McKesson Health Solutions LLC (certified 2003)
CLNC – Medical-Legal Consulting Institute, Inc. (certified 2001 – 2005)
Marquis Who’s Who in Medicine and Healthcare®
(1997 – onward)
ABQAURP Certified Diplomate – American Board of QA & UR Physicians, Inc. (1996 – 2003 )
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