1. Deryl B. Macaulay
Summary:-
 Have over 20 years of experience working as a Registered Nurse and has extensive knowledge
and hands on experience with HEDIS projects.
 Talented health care services professional with extensive experience in hospital, provider and
administration environments; private insurance, Medicare and Medicaid audit proficiency;
currency with ProviderLink™, InterQual® and Meditech software; strong communication and
interpersonal skills from patients through to management; exemplary attention to detail.
Education:-
 University of South Carolina, Columbia, SC
Associate Degree in Science and Nursing 1982
 RN License # 34062
Professional Experience:-
Wellcare - Columbia, SC Mar 2014 to May 2014
Nurse Care HEDIS Management / Quality improvement specialist
 Responsible for overall research and gathering of required documents for HEDIS project, in
collaboration with HEDIS Program Manager
 Assist in the performance Of HEDIS related duties
 Maintenance of reports and spreadsheets
 Gathering information specific to HEDIS measures and verifying accuracy of medical documents.
 HEDIS Reviews of Company medical records
 Worked with Quality Management staff as a team.
 Learned different software programs.
Skills Used
 Detailed oriented.
 Learned Company software intranet, and HEDIS measurements.
 Completed the training for completing the reviews.
Palmetto Physician Connections, Greenville, SC June 2013 - Sept 2013
Part-time Utilization Review Management Nurse
 Worked with MCO to set up the Utilization Review process within the State guidelines.
 Experience with MedHok training and InterQual 2013.
 Performed SBIRT screening for members of PPC.
PRN – Quality Resource Specialist
 Facilitates and coordinates health care team clinical and financial service interventions for
individual and defined patient populations utilizing interpersonal, clinical and organizational
skills
 Assists in identifying quality and cost effectiveness improvement opportunities by collecting and
trending pertinent data
 Provides the nursing component to the case management team
The Carolinas Center for Medical Excellence 1989 – 2005
Medicare/ Medicaid ReviewSpecialist Jul 1996 – Jun 2005
 Reviewed all retrospectively selected medical records for adequacy of documentation and
conformance with established clinical procedures
 Performed Medical Records Review (MRR) for Carolinas Center to make sure the State’s HMO
programs were following HEDIS regulations.

2.  Determined medical necessity and appropriateness of level of care and related procedures by
applying InterQual® criteria
 Ascertained substantiation of diagnostic and procedural information in medical records by
performing DRG (Diagnosis Related Groups) or CPT coding validation
 Ensured documentation standards were met for selected medical records
 Verified demographic data and ensured worksheet completion of all required elements for each
case
 Performed data entry and data retrieval of review results as needed
 Screened each medical record for potential quality issues utilizing established screens and
referred cases when necessary
 Remained current with criteria and procedural revisions
 Made appropriate referrals to physician consultants when utilization and/or quality screens were
not met
 Prepared all necessary correspondence to providers, physicians and health plans relative to review
activities, and communicated with health plans for clarification of external review procedures
 Assisted the Managed Care Review Manager with HMO Administrative Review activities
Clinical Information Specialist Dec 1994 – Jul 1996
 Screened each medical record for potential quality issues utilizing CMS and Medical Review of
North Carolina (MRNC) quality screens, and referred cases when necessary
 Reviewed all selected inpatient or outpatient medical records
 Determine medical necessity and appropriateness of level of care and related procedures using
physician developed screening criteria
 Ascertained substantiation of diagnostic and procedural information in medical records by
performing Diagnosis Related Groups (DRG) or CPT coding validation
 Verified demographic data and ensured worksheet completion of all required data elements for
each reviewed case and perform data entry of results
 Screened each medical record selected for review to ensure that documentation standards were
met
 Performed data retrieval for project data collection as needed and remained current with criteria
and procedural revisions
 Made appropriate referrals to physician consultants when utilization and/or quality screens.
Review Supervisor Sep 1989 – Dec 1994
 Supervised, trained and evaluated Review Specialists and Secretaries in accordance with
established policies and QIO guidelines
 Provided assistance to Review Specialists on the application of screening criteria, modifications
to the review process and revisions to previously established policies and procedures
 Provided educational assistance to Review Specialists where deficiencies in their performance
were identified and additional training was needed
 Assured the timeliness of both chart reviews, and the submission of accurate data worksheets and
medical record information
 Screened cases questioned for appropriateness of acute care. Approved cases meeting acute care
indicators and selected for physician review cases requiring medical determinations
 Prepared and presented questioned cases for physician consultant review and provided assistance
as appropriate for objective decisions to approve or question cases
 Evaluated rationale of physicians’ decisions and presented in written format to the attending
physician and hospital the clinical reason for questioned case
 Scheduled on-site physician reviews to coincide with submission of questioned cases to central
office, including the availability for attending physician phone discussions. Provided for
physician review any case requiring a second determination prior to a final review decision
 Supervised the Records Automated Tracking System (RATS) to assure data accuracy

3.  Maintained current logs and written materials pertaining to the review processes
 Assisted the Director of Medical Affairs and the Medical Advisor with recruitment of area
physicians to serve as physician consultants, and maintained good public relations with medical
community and the general public
 Provided technical assistance (verbal and written) to hospital Administration and Utilization
Review Departments to ensure both QIO policies/procedures and QIO standards were met
 Conducted on-site visits to area hospitals and offered assistance in program implementation to
personnel
 Assisted in program modification
 Provided written and verbal communication to physicians regarding MRNC’s policies and
procedures
 Ensure that confidentiality policies were maintained at all times
Review Specialist Jun 1989 – Sep 1989
 Conducted review activities in accordance with federal guidelines and established policies and
procedures of MRNC.
 Utilized medical criteria and procedure directives in reviewing selected cases and provide for
physician determination cases which are questioned.
Other Employers:
CHAMPUS INSURANCE COMPANY Columbia, SC
Medical Reviewer Nurse II 1987 - 1989
AMERICAN RED CROSS Columbia, SC
Staff Nurse 1985 - 1987
NURSES PROFESSIONAL REGISTRY Columbia, SC
Private Duty Nurse 1985 - 1985
MEDICAL PERSONNEL POOL Columbia, SC
Staff Nurse 1984 - 1985
COLUMBIA PEDIATRICS Columbia, SC
Nurse Assistant (temporary) 1984 - 1984
AMERICAN RED CROSS Columbia SC
Staff Nurse 1983 - 1984
PROVIDENCE HOSPITAL Columbia, SC
Staff Nurse 1982 - 1983
COLUMBIA SKIN CLINIC Columbia, SC
Office Nurse (summer work) 1981 - 1981