Patricia DiLucia
Lansdale
Summary
Experienced, highly organized and tenured Appeal Coordinator with excellent time-management, interpersonal, research, record and data management skills capable of working independently with minimal instruction seeking the Patient Access Case Manager position within Noctrix Health, Inc. where a working knowledge of these skills within the Durable Medical industry will be utilized and expanded to effect Noctrix Health, Inc.requirements in support of business growth and success
Overview
36
36
years of professional experience
1
1
Certification
Work History
Clinical Appeal Coordinator
AmeriHealth Administrators-Independence Blue Cross
02.2005 - 12.2025
- Performed pre, post and expedited medical, pharmaceutical, durable medical equipment and mental health appeal reviews to determine medical necessity in relation to insurance policy benefits, in a fast-paced setting where accuracy and timeliness are critical
- Performed claim appeal reviews for bundling, assistant surgeon reimbursement along with experimental/investigational and benefit exclusion claim denials
- Applied medical criteria including InterQual, corporate medical policy and applicable Federal and State regulations and accreditation standards to establish medical necessity and appropriate level of care
- Coordinated appeal referrals for both internal and external reviews, collaborating with external physician consultants/vendors
- Completed medical record appeal disclosures in accordance with Health Insurance Portability and Accountability Act
Case Manager/Discharge Planner
AmeriHealth Administrators
01.1998 - 02.2005
- Telephonic Case Manager/Discharge Planner for Third Party Administrators, coordinating patient care needs including medical services, supplies and durable medical equipment
- Negotiated with providers for cost containment of services for out of network providers
- Forecasted cost projections and case summary reports for group representatives
- Performed medical necessity for pre, post and concurrent services
- Conducted consultations with onsite Medical Directors as needed
Home Care Coordinator
Allegheny University Hospitals
06.1995 - 10.1997
- Responsible for educating patients, families and other health care professionals regarding home care service eligibility and related insurance coverage
- Formulated individualized plan of care for patients requiring home health services, coordinating with the physician, family and patient
- Coordinated complex home care services and discharge planning, providing patient with a safe transition from hospital to home to ensure appropriate resources - services are in place
Case Manager
Holy Redeemer Visiting Nurse Association
07.1991 - 06.1995
- Simultaneously managed dozens of patient caseloads
- Responsible for performing patient assessments, identifying changes, implementing care and educating patients to improve patient's outcomes
- Preceptor for new employees
- Member of Professional Practice Committee
Team Leader Medical Surgical Floor
Rolling Hill Hospital
05.1990 - 07.1991
- Direct patient care
- Team Lead overseeing Certified Nursing Assistants and Registered Nurses
- Administered medications, assisted with treatments, recognizing changes in patient status and transcribing physician orders
Education
Bachelor of Science - Nursing
Holy Family College
Philadelphia, PACase Management Certification -
Skills
- Healthcare Third Party Insurance Appeals (TPA)
- Managed Care
- Federal Regulations
- State Regulations
- Microsoft Office Suite
- Word
- Excel
- PowerPoint
- Access
- Interqual Criteria
- Medical Policy interpretation
- Claim Policy interpretation
- Pharmacy Policy guidelines
Certification
- Leadership Appeal Representative for Policy and Review Committee
- Subject Matter Expert for Appeals with NCQA Accreditation
- Subject Matter Expert for Appeals with URAC Accreditation
- Foundations Program Participant
Credentials
- BSN
- RN
- CCM
Timeline
Clinical Appeal Coordinator
AmeriHealth Administrators-Independence Blue Cross
02.2005 - 12.2025
Case Manager/Discharge Planner
AmeriHealth Administrators
01.1998 - 02.2005
Home Care Coordinator
Allegheny University Hospitals
06.1995 - 10.1997
Case Manager
Holy Redeemer Visiting Nurse Association
07.1991 - 06.1995
Team Leader Medical Surgical Floor
Rolling Hill Hospital
05.1990 - 07.1991
Bachelor of Science - Nursing
Holy Family College