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Click here or scroll down to respond to this candidateCandidate's Name , RNPHONE NUMBER AVAILABLEEMAIL AVAILABLEProfessional Experience SummaryRegistered Nurse with strong background in utilization review and case management, nursing assessment and clinical research. Skilled in maximizing the quality and cost efficiency of health care services for insurance plan members. Experienced in a wide variety of nursing specialties including NICU, Pediatrics, Cardiac Care, Emergent Care, and Obstetrics. Experience also includes inpatient and home care as a Case Manager and coordinating care for the individual patient. Performed Personal care aide Supervision reviews as required by NYS. Adept at efficiently allocating medical resources while ensuring each patient gets the appropriate level of medical care. Specialize in finding a balance between the fiscal needs of the organization and the care needs of each patient.Skills & QualificationsUtilization Review Clinician (Molina Healthcare/Lancesoft)03/2022- 8/2023UM Nurse for Molina Healthcare insurance - Ensured appropriate medical benefits are applied to services reviewed for medical necessity, using MCG system, NYS policy and focusing on Medicaid, and government plans Served as liaison between members, providers, and insurance plan, reviewing medical history and policy as well as performing calls as needed to obtain additional information needed for determination of coverage, or notification of approvals and adverse determinations. Reviewed clinical documentation and medical records to determine if proposed treatment plan is medically necessary and appropriate per medically accepted clinical review criteria, recommending certification of proposed treatment plan, and performing calls to members with authorizations, or if not supported, referring to clinical review physician for denial and issuing denials.RN Case Investigator NYS DOH Hudson County (Execu- Search) 09/2021 01/2022Case investigator performs research on positive Covid-19 cases, obtains contacts, symptoms, and medical history, obtains contacts, and performs patient teaching on isolation period, signs and symptoms to seek emergency care. Documents all required information into database and notifies supervision when clusters are found.Medical Management Review Nurse (Total-Med/Blue Cross Blue Shield) 06/03/2021-8/2021Utilization Review nurse contracted with Anthem Blue Cross Blue Shield. Reviews inpatient requests for medical necessity, documents all pertinent information and submits for PCR review when not meeting criteria. Execu-Search/NYS Department of HealthRN Vaccinator for NYS DOH 01/2021-05/2021Reviews past medical history, patient education, administers Covid-19 vaccine, assesses for adverse eventsRequests NP evaluation for contraindicated administrations Admission Nurse (The Grand Rehabilitation and Nursing Home) 11/2020- 1/2021Performs admission assessment and obtains MD orders, documentation of patient status and plan of care.Performs supervision duties for facility when no staff available, including finding staff to cover shifts, med passes and kitchen duties when needed. Utilization Review Nurse (TotalMed) 3/2020-7/2020UM Nurse for Monroe Health insurance - Ensured appropriate medical benefits are applied to services reviewed for medical necessity, using Interqual system, NYS policy and focusing on Medicaid, and government plans Served as liaison between members, providers, and insurance plan, reviewing medical history and policy as well as performing call outs as needed to obtain additional information needed for determination of coverage Reviewed clinical documentation and medical records to determine if proposed treatment plan is medically necessary and appropriate per medically accepted clinical review criteria, recommending certification of proposed treatment plan, and performing calls to members with authorizations, or if not supported, referring to clinical review physician for denial and issuing denials. Assessed requests for prior authorization of services for Medicaid, and government plans for requests for out-of-network coverage. RN Case Manager (Aetna/CVS company) 11/2018-8/2019Partnered with healthcare team, including social worker, physician, and ancillary services providers, to identify and implement methods to reduce complex case readmissions Performed regular outreach to members with chronic disease states such as diabetes, coordinating care and ensuring compliance with healthcare regimen Coordinated inpatient and outpatient care and follow-ups, reaching out to members pre- and post-procedure and providing education on disease state/ management.Utilization Review Nurse (Fidelis/Centene) 08/2015-11/2018 Ensured appropriate medical benefits are applied to services reviewed for medical necessity, using MCG system, Fidelis policy and focusing on EP, HBX, Medicaid, and government plans. Constant documentation and review of all charts for compliance of NCQA Accreditation Served as liaison between members, providers, and insurance plans, reviewing medical history and policy as well as performing calls as needed to obtain additional information needed for determination of coverage Reviewed physician documentation and medical records to determine if proposed treatment plan is medically necessary and appropriate per medically accepted clinical review criteria, recommending certification of proposed treatment plan and issuing authorization letters, or if not supported, referring to clinical review physician for denial and issuing denials. Assessed requests for prior authorization of services for Medicaid, and government plans for requests for out-of-network coverage Referral services Case Manager (CDPHP) 06/2013- 09/2015Ensured appropriate medical benefits are applied to services reviewed for medical necessity, using MCG system, CDPHP policy, NYS and Federal Mandates, focusing on EP, HBX, Medicaid, Medicare, CHP, and ASO company plans. Exceptional documentation of all communication, per HEDIS, Stars, NCQA Accreditation. Served as liaison between members, providers, and insurance plans, reviewing medical history and policy as well as performing call outs as needed to obtain additional information needed for determination of coverage Reviewed physician documentation and medical records to determine if proposed treatment plan is medically necessary and appropriate per medically accepted clinical review criteria, recommending authorization of proposed treatment plan and issuing authorization letters, or if not supported, referring to clinical review physician for denial and issuing denials. Assessed requests for prior authorization of services for Medicaid, and government plans for requests for out-of-network coverage Case Manager II (WellPoint/Blue Cross Blue Shield)04/2011-05/2013Performed Case Management of patient care by telephonic assessment and teaching, worked with social work, and medical directors for high- risk patients.Performed Utilization Review for my patient load- inpatient and outpatient procedures, DME, Rehabilitation, and DME.Perform patient teaching, what to expect, assess knowledge of proposed procedures, and advisement of best outcomes, compliance of medication and follow up, approvals of continued necessary medications/foods when patient/child has no alternative means of nutrition or necessary medications. Checking in with members telephonically, assessment of mental health, support system and assisting with finding providers when needed.Weekly team meetings on high-cost members to see if other members of team (ie- Medical Director, Social Work) have any different ideas when a member is deemed high risk and non-compliant.Clinical Research Nurse (Albany Medical College/Hospital)10/2005- 04/2011Coordinated multiple clinical studies simultaneously, providing clinical and administrative support by serving as liaison between patient and scheduling patients for exams and tests in accordance with study protocols. Identified, screened, and enrolled study subjects consistent with study procedures and collected documentation, ensuring lab and diagnostic data was obtained according to established protocols. Provided direct patient care, administering patient evaluations in addition to obtaining health history, informed consent, and other required documentation. Prepared and submitted required forms and reports to IRB, ensuring compliance with study procedures, budget, and established guidelines. Educated Staff (Nurses/Physicians/Residents) on protocols and assisted with obtaining Research Certification. Enlisted assistance from Research Director group to perform mock audits for upcoming FDA audits. Follow up calls to study participants to inquire about any adverse events and sending out checks for paid studies.Education & CredentialsAssociates of Applied Science in Nursing Maria College of Albany BSN/MSN in progress at SUNY POLYTECHNIC UTICA/ROME |
