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Click here or scroll down to respond to this candidateCandidate's Name
Street Address
Cell Phone PHONE NUMBER AVAILABLE * Email: EMAIL AVAILABLE QUALIFICATIONSRegistered Nurse with a Bachelor of Science in Nursing, with 36 years of Nursing experience. These areas include:Case ManagementUtilization ReviewDisease ManagementClinical Documentation SpecialistClinical TransformationHome Health Care and Home InfusionIntensive Care, Emergency Room, Telemetry, Hemodialysis Quality Improvement in an HMO settingKnowledge of Meaningful use reportingExperience with ICD-9 and CPT coding, and billingSKILLSAutonomous/independent decision makerDependableExcellent problem-solving skillsStrong communication skillsExcellent clinical skillsSupervisory / ManagementComputer and Software skills:Cerner, Citrix, EPIC, MIDASInterqual3M HDM computer assisted coding software,MPRO and Milliman & Robertson Length of stay protocols, NCQA and HEDIS/MDCH reportingMicrosoft Word, Power Point, Excel, Access and Outlook WORK HISTORY4/2019 Present Appeals / Denial Coordinator remote naviHealth Write denial letters to members when appeals are denied. Data entry for new appeals, faxed information to third party payer and member. Contact Acute Care, SNF, LTAC, LTC and Rehabilitation facility when members lose or win their appeal. Data entry for all appeals and denials. 7/2020 9/2020 Harmony Health Contractual Agency follow-up of denied and rejected claims from all commercial, contracted and non-contracted payers, including preparing appeal letters. Reviews all denials for medical necessity and appeal ability utilizing clinical judgment and applying InterQual criteria. Provides clinical utilization management expertise. Provided education, formal and informal, to facilitate denial management strategies. Serves as a liaison to ancillary departments, physicians and payers.11/2011 - Present Case manager - Henry Ford Macomb Hospital (11/11 Present) Reviewed patient charts to ensure expedient and quality of care was being delivered. Reviewed patients chart in the ER to ensure patient meets criteria for inpatient status. Assigned patient to appropriate bed. Coordinated home care, discharge planning, direct admissions, and patient transfers. Ordered and coordinated DME and oxygen. 01/2017- 03/2019 Case Manager / Clinical Documentation Specialist/ UR St. Joseph St. HospitalReviewed patient charts to ensure expedient and quality of care was being delivered. Monitored LOS days and informed physicians when patient no longer met criteria as an inpatient. Coordinated home care, discharge planning and patient transfers. Attended patient care rounds with physician. Supporting of clinical systems for assigned site(s) ensuring that clinical processes are accurately reflected and supported. Educated and supported employees during the transition from paper charts to electronic medical records.1/2014 7/2017 St. John Ascension Clinical Transformation (Full time to contingent) Supporting of clinical systems for assigned site(s) ensuring that clinical processes are accurately reflected and supported. Educated and supported employees during the transition from paper charts to electronic medical records.07/12 01/14 Clinical Transformation Specialist - Detroit Medical Center Supporting of clinical systems for assigned site(s) ensuring that clinical processes are accurately reflected and supported. Educated and supported employees during the transition from paper charts to electronic medical records.11/07 07/12 Clinical Documentation Specialist Detroit Medical Center Performed concurrent documentation review to clarify conditions, diagnoses, and procedures, assisted coders with concurrent review of inpatient medical records. Collaborated with coders and queried physicians for missing, unclear, or conflicting health record documentation by requesting and obtaining additional documentation within the health record before patient is discharged.07/07 - 11/07 Clinical Documentation Specialist Triumph Health Care (Position eliminated) (See job description above)09/06 07/07 Clinical Documentation Specialist St John Riverview (Hospital Closed)(See job description above)2003 - 2006 Providence Hospital Home infusion Nurse 1998 9/2003 Acting Quality Improvement Manager and Medical Record Review Coordinator - OmniCare Health Plan (6/2000 11/2003) Medical record and site reviews for credentialing, re-credentialing, quality issues and new offices. Follow up with offices that receive Corrective Action Plans. Coordinate data collection for HEDIS reporting, data entry and submission of DST to NCQA. Responsible for Quarterly State Reports and data entry. track, log and analyze companywide QI issues and consumer complaints. Performed Quality Improvement Analysis. Supervised Site Review Nurses and Disease Management staff during medical record review. Coordinated medical record reviews, interacted with all consultants who were contracted to assist with the NCQA reporting, CAHPS and state reporting. Worked closely with the Chief deputy Officer and IT department to determine what methods or solutions could be used to increase our NCQA scores. Acting manager for Disease Management Department, Disease Management Coordinator - OmniCare Health Plan (12/98 6/2000) Responsible for the development and maintenance of Preventive Health and Disease Management Programs. Educated members as well as providers on clinical guidelines and available programs. Tracked, logged, and analyzed member activity and due dates for preventive health visits and annual visits for maintenance of disease processes. Sent out reminders and educational materials to members and providers. Responsible for developing new interventions and implementing them to increase member and provider participation in patient self-care. Developed Policy and Procedures for Disease Management area. Supervised one RN, LPN, and Secretary. Utilization Review Coordinator - OmniCare Health Plan (2/98 12/98) Telephonic reviews from hospitals and gave length of stay days. Consulted with Physician assistant on cases in question. Sent denial letters to hospitals, forwarded quality issues to the QI department for further investigation.1995 2000 Case Manager - Mercy Hospital of Detroit Reviewed patient charts to ensure expedient and quality of care was being delivered. Coordinated home care, discharge planning, direct admissions, and patient transfers. Ordered and coordinated DME and oxygen. 1989 2005 Intensive Care, Step Down and Emergency Room Nurse: Trauma Nurse Agency, Mercy Hospital of Detroit, Michigan Osteopathic, Detroit Riverview Hospital and Detroit Osteopathic Hospital Detroit Total Care for Critically ill patients, management of Ventilators monitoring and settings, Cardiac out puts, Central lines, and A-lines. 1987 2000 Home Care Nurse Residential home care, Neo Home Health Care, Michigan Cancer foundation home care.1986 1989 Medical Surgical Nursing Harper Hospital, Grace, and Sinai Hospital Total patient care.03/05 11/06 Home Infusion Nurse - St. John/Providence Hospital (03/05 11/06) Instructed patients going home on TPN, antibiotics, pain medications or Tube feeding how to infuse medication, operate pumps, side effects of medications, coordinated delivery of medications and case managed the case.EDUCATION1990-1992 Bachelor of Science in Nursing, Wayne State University 1983-1986 Associate Degree of Nursing, Highland Park Community College REFERENCESHeidi Somonato-Flake, RN, MSNManager of Case ManagementSt. Joseph Mercy HospitalCell: PHONE NUMBER AVAILABLEVernal T. Blane, RN, PHDDirector to Utilization Review42573 Saddle LaneSterling Hts., MI 48314Telephone: 1PHONE NUMBER AVAILABLEBrenda Etefie, RN, MSNDirector of Clinical DocumentationDetroit Receiving HospitalDetroit, MI 48214Work: PHONE NUMBER AVAILABLECell: PHONE NUMBER AVAILABLEJill Vos-Winowski, RN, MSNManager Henry Ford Macomb HospitalGarfield & 19 Mile Rd.Clinton Township, MI 48038Cell: PHONE NUMBER AVAILABLEGeorgia Brown, RN, MSN, NPDirector of Care Management & SWDetroit Riverview Hospital29590 Woodhaven LaneSouthfield, MI 48075Home: PHONE NUMBER AVAILABLENovember 23, 2022To Whom It May Concern:My name is Candidate's Name , I am a Registered Nurse with a Bachelor of Science in Nursing. I have 36 years of nursing experience in many different areas. My areas of expertise include but are not limited to:Case ManagementUtilization ManagementClinical Documentation SpecialistICU, ER, Telemetry, Hemodialysis, and Medical/Surgical Nursing Home Infusion Nurse and Home Health Care NursingQuality Improvement CoordinatorActing Quality Improvement ManagerActing Disease Management ManagerClinical Transformation Implementation, Education, Training and adoption Process ImprovementRegulatory reporting: HEDIS, MDCH utilization reports NCQA preparation and reportingMedical Record Review Analyst and CoordinatorSite Review CoordinatorDevelopment of department policies/proceduresProject ManagementMy clinical skills mirror my administrative skills. Attached for your review is a copy of my curriculum vitae. I have 30 years of Case Management, 17 years of Utilization review experience, and 17 years of ICU experience along with 11 years of Clinical Documentation experience. I hope that you find that my expertise will be useful within your organization. I look forward to discussing career options with you soon. I may be contacted at PHONE NUMBER AVAILABLE Thank you in advance for your time and consideration. Sincerely,Candidate's Name , RN, BSN |
