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Click here or scroll down to respond to this candidateCandidate's Name
Richmond, VA Street Address PHONE NUMBER AVAILABLE EMAIL AVAILABLEDedicated and compassionate professional with a progressive career history in direct patient care, medical authorizations, documentation review, risk management, care coordination, and compliancy. Analytical and detailed with excellent problem-solving and time management skills. Seeking a challenging position that will allow my skills to be an asset in the medical, legal, or government sector. Direct Patient CareCare CoordinationRisk ManagementCase and Documentation ReviewCompliance and State RegulationsProcess MonitoringMultidisciplinary Team CollaborationData Collection and AnalyzationPrior Authorization Review Nurse, 11/2017 - Current AETNA BETTER HEATH OF VIRGINIAUtilizes clinical skills to support coordination, documentation and communication of medical services and benefit administration.Collects information to support the process of rendering appropriate medical necessity/benefit determinationsIdentifies members for referral opportunities to integrate with other products, services and programs. Utilizes clinical experience, criteria,guidelines, policies and procedures in support of making timely and accurate medical necessity/benefit determinations. Nurse Reviewer, 08/2006 - 09/2017KEPRO-Innovative Healthcare Management SolutionsPrepared cases for physician review; recorded review results to perform prior authorizations for patients. Reviewed and interpreted patient records to compare against criteria in order to determine medical necessity and appropriateness of care.Determined if the plan of care was followed in a timely manner and that the medical documentation PROFESSIONAL SUMMARYSKILLSWORK HISTORYsupported the delivery of quality care.Ensured that providers meet regulatory and risk management criteria to minimize liability to the company. Outpatient Review Analyst, 10/2003 - 06/2006West Virginia Medical InstituteReviewed provider requests for outpatient care services. Utilized appropriate standards of medical necessity, current criteria specified in the appropriate program manuals, state regulations, contractual directives, and professional judgment to render a prior authorization decision for requested services.Works independently and with other health care professionals and departments. Licensed Practical Nurse, 11/2002 - 08/2003Hallmark Youth Behavioral Care CenterPerformed the duties of both charge and staff nurse in a residential treatment center environment. Administered medications, process with clients and set limits as deemed necessary. Keep detailed records of patient care to coordinate additional care or services when necessary. Licensed Practical Nurse, 06/1993 - 11/2002Department of Veterans AffairsPerformed the duties of a staff nurse in the geriatric, cardiac, and telemetry units of the hospital. Administered medications and patient care proactively. Performed EKGs and other various testing as prescribed. Customer Service Collection Rep/Skip Tracer, 05/2000 - 12/2001 Heilig Myers Corporate Office-Call CenterAnswered inbound calls and provided energetic customer service to customers making payments or setting up payment arrangements.Updated customer information, made outbound calls to customers regarding payments on accounts and relayed the information to other departments within the company. Communicated information regarding charged off accounts to other financial institutions and collection agencies.Skip traced accounts for current address and telephone information, and pulled credit bureaus as required on an individualized basis.Internship Position, 02/1999 - 06/1999Court of Appeals of VirginiaAssisted with the secretarial responsibilities for Senior Judges such as typing, proofreading, and rewriting case opinions.Retrieved briefs and appendices, which were prepared for summary disposition, petition for appeal and procedural defect cases.Associate in Applied Science, Legal Assistant Program: 05/2000 J. Sargeant Reynolds Community CollegePractical Nursing Certificate: 03/1987St. Mary's Hospital School of Practical NursingHigh School Diploma: 06/1986Henrico High SchoolPractical Nursing License with the Commonwealth of Virginia, #0002038704 EDUCATIONLICENSE |
