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Click here or scroll down to respond to this candidateCandidate's Name , RN, MBA, CCMRN License #Street Address A3969 E. Boltinghouse RoadBloomington, IN 47408PHONE NUMBER AVAILABLEVision: I am looking for a company to provide my vast nursing experience and enhance mycontinuing education. I enjoy challenges and helping to expand healthcare in its every evolvingdynamic structure.QUALIFICATIONS42 years as a Licensed NurseCertified Case Manager (Case Managers Society of America)8 years Acute Care Utilization/Case Management23 years in the Insurance Industry doing Utilization Review/Case ManagementImplemented 3 Utilization/Case Management programs, acute settingsImplemented and Managed an Internal Medicine Physician Office and Family PracticeWork compensation and Mental Health /Substance Abuse UR/Case ManagementWORK HISTORYAugust 2,2021-Current: PayerCompass/ZELIS, RN Case Manager.UM/CM for TPAs.Managing 60-70 cases per month.Average cost savings of $354,761.46.Turn around time for utilization less than 8 hours.Audits at greater than 90%, goal at greater than 90%.Assessments done in 30 days time frame consistently.Bill time 182 hrs per month, with goal at greater than 100 hours.Clinical Assessment of policies and procedures.Milliman Care Guidelines, NCCN guidelines utilized.Jan 16, 2018 -April 2021: Anthem Blue Cross, RN National Commercial Accounts Case Manager/SRCase Management, Disease Management, Complex Case ManagementFeb 25, 2019, IHM-FedEx: National IHM AtlantaMilliman Care Guidelines/NCCN utilized.July 7, 2014-January 1, 2018: SIHO Insurance Services, RN Case Manager/RN Utilization Review Nurse (for TPA accounts with >35,000 lives)2017 CASE MANAGER FOR THE TEAMSTERS ACCOUNT > 3000 LIVESPreceptor for new employeesRN Medical Management for TPA accountsWC City of Bloomington 700 livesPsych Medical ManagementMonthly ReportsContinuing EducationMilliman Care Guidelines/NCCN utilized.December 12, 2011- June 30,2014: Dr. Kristina Morris, Family Eye Care, Billing, and Insurance SpecialistAll aspects of physician billing and insurance coordination for Office VisitsDaily Chart AuditsMonthly billing and CollectionsCredentialingCompulink Resource for the office (EHR)June 2011-December 28, 2011: IU Health Southern Indiana Physicians, Clinical CoordinatorStaff SchedulingOrdering SuppliesStaff TrainingElectronic Health Record TrainingOctober 2010-July 2011: Indiana University School of Optometry, Bloomington, Billing Support SpecialistFiling of claims with Anthem, Medicare, and MedicaidCustomer Service Calls and Problem solvingCollected from Anthem with re-billing corrections thousands of dollarsTemporary/Hourly positionNovember 2009-September 2010: Visiting Nurse Service, Morgan County Branch, RN Case ManagerHome health care that involves teaching, PICC line care, IV care, wound care, wound vacs and disease management for teens through Seniors.Traveling over 5 counties, over 2,000 miles per month.Branch closed in December 2010.September 2007-November 2009:Golden Living Long Term Care Healthcare Center, Director of Clinical Education and Staff Development/MDS CoordinatorAspects of job included duties in Human Resource development and clinicaleducation for the staff as Director of Clinical Education.Training of CNAs for Electronic Medical RecordsNursing assessments for Medicaid and Medicare per MDS standards for billingPurposes and care planning the individual residents needs.Successful survey team member. Represented Education and Staff DevelopmentHelped gain 2 x reimbursements as MDS coordinator for Medicare and MedicaidPatients.Successful State Board of Health SurveySuccessful Chart Audits by State Board while under MDS Coordinator positionInstructor for CPR/AED/First Aid and clinical education for staffApril 2007-September 2007: Monroe Family Practice, RN Practice ManagerStarted the Monroe Family Practice with two physicians. All aspects of officemanagement responsibility and start up including physician recruitment.Position was dissolved when several contracted physicians decided not to re-locateto Bloomington, IN.Cared for all age groups in this family practiceSeptember 2006-April 2007:Monroe Hospital, Director of Utilization Review Coordinator/Case ManagerStarted the UR/CM program for the new hospital in Bloomington, INSet up policies and did insurance review as well as quality indicators for qualitymanagement and financial reports.Also was the Interim Director of the Medical Surgical Unit and developed andopened the Progressive care unit.July 2001-September 2006: Bloomington Hospital and Healthcare System, Staff/Charge NurseCritical Care Unit/Cardiovascular Recovery UnitHelped originate the Cath Lab pre/post op area on 3 NW.October 1997-July 2001: Morgan County Memorial Hospital, Director of Utilization/Case Management Department.Implemented and designed Utilization/Case Management Program at MCMH.Instituted Clinical pathways for Medical/Nursing Staff, a designee on the ClinicalPerformance Improvement Committee and instituted the Multi-disciplinaryCommittee.Infection Control Surveillance Officer and Mortality ReviewCoordinator, Employee health and Infection control officer as needed.Assisted with Social Service duties when needed and helped with Joint CommissionSurvey.Jan.1995-October 1997: Anthem Health of Indiana, Disease State Management Coordinator for AsthmaDeveloped and implemented the Asthma case management program for the state ofIndiana for Anthem Health for infant through seniors age groups.1995-1996: Heritage Indiana Medical Group, Director of Utilization/Case Management Department.Implemented case management department and managed seven employees. CaseManagement department savings of $200,000-500,000 per month.Budget and Strategic planning for the department.Utilized Milliman Care Guidelines and NCCN.May 1995: Odyssey Health Consultants, RN Consultant, Development of a Managed ServicesOrganization in Johannesburg, South AfricaSpeaker for the first meeting of The Case Manager Society of South Africa.Instituted Case Management department in Johannesburg, SA1994-1995: Hospice of Indianapolis, Provider Relations CoordinatorInteracted and influenced the referral patterns of healthcare professionals inHospitals, home health agencies, nursing homes and private practice of physicians.Developed the Hospice program for several counties in Eastern Indiana.1993-1994: Dialysis Institute of Indiana, Staff/Charge NurseOpened and managed a new facility at Northwest Indianapolis for dialysis patients. ChargeNurse of 32 patients per 2 shifts and 11 technicians.1992-1993: Sagamore Health Network, Utilization Review CoordinatorUtilization and case management coordination of psychiatric and medical patients.Milliman Care Guidelines utilized. CMS and NCCN guidelines utilized.1980-1986: 1990-1992: Wishard (Eskenazi)Memorial Hospital, Staff/Charge NurseEmergency Room. Level One Trauma Center.Medical/Surgical Unit (1980-1982) that received many patients from the SICU(1982-1985) Medical-Surgical unit, Post Anesthesia Care Unit, Staff Nurse.EDUCATION*Hospital Bill Review certification-1/31/23*LNC, Legal Nurse Consultant certificate-2018*MBA, Indiana Wesleyan University, December 1998* BSN, Indiana Wesleyan University, May 1994* ASN, Indiana University, May 1991*LPN, Indiana Vocational Technical College, August 1981CERTIFICATIONS*CCM, # 4217766 December 2, 2015- November 30, 2025*Certification for Care Guidelines Specialist April 18, 2016- April 18, 2018 (Milliman Guidelines)*CPUR-1998 Certified Professional in Utilization ReviewORGANIZATIONS/ASSOCIATIONS*American Association of Legal Nurse Consultants*Ellettsville Mini 4-H, Co-Leader, 2007-2010*American Nurses Association*Member of American Association of Managed Care Nurses*Unionville Hot-shots, Co-Leader for 4-H group*Past Volunteer for 4-H community eventsEHR SYSTEMSAllscripts, McKesson, Compulink, New Crop, OAO, HSP, AS 400, Web-based programming, AvedonLicensureIndiana-compact licenseNew YorkCaliforniaColoradoPennsylvaniaDistrict of ColumbiaMichiganOhioNevada |
