Deborah Alderiso

RN with 40+ years of experience spanning HEDIS auditing, medical record review validation, utilization management, quality assurance, and appeals and grievances across Medicare, Medicaid, and commercial healthcare environments. Recognized for strong audit accuracy, productivity, and clinical judgment in high-volume remote review settings, with a consistent ability to identify documentation gaps that support compliance, quality performance, and revenue protection.

Background includes home health, managed care, reimbursement auditing, utilization review, and hospital operations across six states.

Clinical Quality Specialist – Medical Record Auditor, HEDIS - Centene - Remote

(2020-12)

Problem Solved: Improved audit consistency and abstraction accuracy across HEDIS projects while maintaining 96%–97%+ quality scores and exceeding productivity expectations in high-volume remote review environments.

• Conduct internal audits to ensure compliance with NCQA HEDIS specifications, accreditation standards, and regulatory guidelines.
• Perform HEDIS over-reading, abstraction review, and rateMax activities across multiple quality initiatives.
• Participate in quality improvement workgroups focused on improving abstraction accuracy and closing care gaps.
• Analyze audit findings and identify opportunities for process optimization and documentation enhancement.
• Serve as a clinical resource supporting quality performance and regulatory readiness.

Clinical Quality Auditor - Preferred Nursing Services – Home Health - Remote

(2018-07 - 2024-01)

Problem Solved: Improved documentation consistency and reduced compliance risk exposure through workflow enhancements, staff training, and targeted quality improvement initiatives.

• Conducted utilization reviews and audited patient plans of care for regulatory and clinical compliance.
• Reviewed OASIS assessments for coding accuracy, sequencing, medical necessity, and homebound qualification.
• Evaluated documentation consistency, nursing interventions, physician orders, and patient goals.
• Developed software templates supporting standardized nursing documentation and care planning.
• Supported quality assurance and performance improvement initiatives aligned with CMS benchmarks.

Clinical Quality Specialist – HEDIS - ALLMED Staffing / United Health Group - Remote

(2016-01 - 2020-12)

Seasonal Contract Engagements. Problem Solved: Strengthened HEDIS compliance workflows and vendor abstraction accuracy while exceeding quality metrics and earning multiple Diamond Recognition Awards.

• Audited vendor medical record abstractions for HEDIS accuracy and compliance.
• Performed claims investigations and analyzed QSHR, HTA, ISET, ILEAD, and FACETS data.
• Conducted rateMax activities and supported provider outreach for clinical record retrieval.
• Served as clinical point person for contractor teams and quality initiatives.

Revenue Auditor Contractor - Computer Task Group (HMS Healthcare) - Remote

(2017-09 - 2017-12)

Problem Solved: Strengthened billing accuracy and supported revenue recovery initiatives through detailed utilization review and claims validation.

• Conducted retrospective claims reviews for inpatient skilled nursing facilities.
• Validated resource utilization group billing against medical record documentation and medical necessity criteria.
• Reviewed clinical documentation to determine appropriateness of billed services and reimbursement accuracy.
• Revised claims based on review findings and prepared detailed provider summary reports outlining review rationale and findings.
• Collaborated with internal review teams to support audit accuracy and regulatory compliance standards.

Appeals and Grievance Auditor - JUDGE / United Healthcare - Remote

(2017-06 - 2017-08)

Problem Solved: Accelerated identification of workflow deficiencies during pilot audit operations and improved visibility into compliance gaps.

• Audited appeals and grievance workflows from intake through resolution.
• Documented audit findings and maintained tracking databases for compliance reporting.
• Evaluated process adherence and identified operational deficiencies.
• Reviewed case documentation for compliance with internal policies, regulatory standards, and turnaround requirements.
• Supported quality assurance initiatives by identifying trends and escalation points within grievance operations.

Case Management Auditor - Total Med / Wellcare - Tampa, FL

(2017-05 - 2017-06)

Problem Solved: Identified deficiencies impacting compliance performance and CMS timelines while supporting improvements in assessment documentation and care planning accuracy.

• Audited CMS-mandated member risk assessments for compliance and timeline adherence.
• Evaluated discrepancies and developed care plans based on assessment outcomes.
• Reviewed documentation for completeness, accuracy, and alignment with CMS requirements.
• Reported audit findings and assisted with identification of process improvement opportunities related to member assessments.
• Supported care management compliance efforts through detailed review and analysis of risk assessment activities.

RN Quality of Care Reviewer - KEPRO - Tampa, FL

(2014-09 - 2015-08)

Problem Solved: Improved review efficiency and strengthened compliance processes without increasing operational workload.

• Conducted concurrent and retrospective quality-of-care reviews for Medicare beneficiaries.
• Reviewed inpatient, outpatient, home health, hospice, and specialty provider records.
• Developed detailed physician review summaries and disclosure communications.
• Participated in process improvement and quality assurance initiatives.

Additional Clinical Roles - Multiple Employers - New York, New Jersey, Rhode Island, Massachusetts, Florida, Arizona

Earlier experience includes progressive nursing and leadership roles spanning Case Management & Utilization Review, Home Health & Pediatric Nursing, Revenue Integrity & Appeals Management, Emergency Department & Critical Care Nursing, Long-Term Care Leadership, School Nursing & Health Education, Travel Nursing & Hospital Staffing Assignments, and Managed Care & Health Insurance Advising.

Bachelor of Science in Nursing (BSN) - Nursing & Education - Wagner College

School Nurse / Instructor Certification - Nursing Education - Jersey City State University