Emily Petersen

Known for her meticulous approach to documentation, claims, and policy reviews, Emily has developed an expertise in medical record analysis. She focuses on the severity and complexity of individual cases, ensuring adherence to ICD-10/CPT coding and compliance with CMS and payor guidelines. She is proficient in performing quality-oriented documentation reviews in accord with regulatory standards. Emily’s clinical experience is rooted in hands on nursing, including participation in clinical research trials and training at academic medical centers affiliated with Yale University School of Medicine and Harvard Medical School. Her background in critical care nursing includes participation in staff development and training at hospitals affiliated with Yale University School of Medicine and Harvard Medical School where she worked in the Coronary ICU and Cardiac Catheterization Lab. She engaged in critical care nursing for cardiac, neurologic, major surgery, chronic medical and hospice patients while assisting medical and surgical staff during invasive procedures.

Emily’s professional experience includes:

• Emily is instrumental in providing consultative clinical services attorney-mediated medical record reviews in fraud and abuse investigations as part of a multidisciplinary team. She has conducted long-term reviews for acute-care facilities under a corporate integrity agreement from the OIG. She has participated in meetings with the Department of Justice on behalf of clients being investigated under the False Claims Act and assisted counsel in the preparation and delivery of voluntary disclosures and refunds to the government. Additionally, she has worked with facilities to improve controls and reporting to state Medicaid and Medicare agencies and instituting workflows ensuring future compliance.
• Emily is a Certified Risk Adjustment Coder (CRC) with expertise in reviewing medical records and assigning accurate medical codes for services provided by physicians and other healthcare providers in the office or facility setting. She has worked with large Medicare Advantage plans and provider groups in conducting internal audits. Emily has a strong understanding of RADV, the audit process for risk adjustment models and determining correct HCC assignment. Additionally, she has successfully identified and communicated documentation deficiencies to providers to identify opportunities to improve documentation for accurate risk adjustment coding.
• The types of matters Emily has been involved with include: long term acute care lengths of stay (LTAC), medical necessity reviews of internal cardioverter defibrillators (ICDs) and PTCA/stents, one-day stays, skilled nursing, adult and geriatric psychiatry, due diligence reviews, concurrent surgery reviews, and the off-label promotion of drugs. She is adept in the use of Inter Qual and Milliman Care Guidelines.
• Emily has prior experience at a Fortune 200 HMO, coordinating inpatient, outpatient, home health, ambulance transport, and hospice benefits for both Medicare and Commercial members as a regional manager of utilization review. She was a certified Inter Qual™ Instructor and had responsibility for all training of regional medical management clinicians in the principles of medical necessity and utilization review criteria.