Amy K.

Healthcare organizations don't just need compliance — they need compliance that works when it's tested. I'm a Licensed Practical Nurse (LPN) with 22 years of clinical experience and an MBA in Healthcare Administration, with over a decade inside managed care organizations including Highmark Health, Capital Blue Cross, and Centene. I've spent my career at the intersection of clinical operations and regulatory compliance — which means I understand not just what the rules say, but how they play out on the ground. I work independently with health plans, healthcare technology companies, medical facilities, DME companies, behavioral health organizations, and home health agencies across three service areas: REGULATORY COMPLIANCE & DOCUMENTATION I build and refine the documentation infrastructure organizations depend on — policies and procedures aligned with CMS, Medicaid, NCQA, and state DOH standards; SOPs and workflow documentation; compliance gap analysis; and regulatory readiness including mock audit support. HEALTHCARE TECHNOLOGY & PLATFORM SPECIFICATIONS I translate regulatory requirements into functional system design. I've developed foundational prior authorization platform specifications for AI-assisted submission tools, designed JCI-aligned accreditation platform architecture for new healthcare facilities, and advised on federal compliance obligations under the No Surprises Act. If your product or platform touches healthcare regulation, I can write the rules it needs to follow. INSURANCE DENIAL & APPEALS I write denial appeals that are hard to dismiss — because I know how payers review them. I handle prior authorization and claim denial appeals, build medical necessity arguments using InterQual, MCG, Medicaid, and CMS criteria, and provide denial management consulting for practices with high denial volumes. My years inside health plan utilization management is the advantage your appeal needs. Whether you need compliant policies built from scratch, a regulatory framework translated into platform specifications, or a wrongful denial overturned — I bring the clinical knowledge and regulatory depth to get it done. My services do not constitute legal advice. For legal representation, please consult a licensed healthcare attorney.