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Click here or scroll down to respond to this candidateCandidate's Name , RN, MHS, MBAEMAIL AVAILABLEPHONE NUMBER AVAILABLEProfessional Experience03/2019 to present Utilization Management Nurse, atIndependence Blue CrossUtilization reviews of Emergency /Urgent care cases in order to render a determinations for inpatient medical care. Assure reviews meet Interqual Criteria/IBC or CMS criteria for inpatient level of care . Other responsibilities include but not limited to data abstraction, write up reviews, communicate with senior nurses, managers, and medical directors for authorization and coordination of services.6/13/16 to 6/6/17Cigna Health SpringsUtilization Review NurseRetrospective and precertification review of ambulance, physical, occupational, speech, social work, home health aide, and documentation for compliance in accordance with CMS standards and Cigna Organization Policy to meet approval for authorization of servicesReview therapy and home health claims, physician, inpatient and outpatient acute and ambulatory, medical record review for clinical content, to meet Interqual and Millenium Criteria.6/2015 to Present - Per Diem Nurse Supervisor atGeneral Healthcare Resources at Long Term Care Facilities Duties: Documentation on electronic medical record, Medication administration, assessment, planning, implementation and evaluation of care.RNAC at a Long-Term Care FacilitiesComplete MDSs, clinical medical record review for clinical content, verify correct coding for billing submissions, medical record submissions to CMS, update care plans, insurance verifications, Utilization Review, Case ManagementJennersville Home HealthHome Health RNComplete the OASIS, admit patients to home health services, complete start of care, assess the patient, wound care, diabetic teaching and monitoring, respiratory assessment and management, mini nebs, teaching for new diabetics, wound care, medication prefill, teaching patients injections, catheter care IV medication administration, and after care following surgical procedures, wound care post op surgical care2003- 11/2014Genesis Health Care and Genesis Staffing, Kennett Square, PA,Clinical Registered Nurse Supervisor (part time & per diem)Long term care, nurse supervisor, medications,assessment, planning, implementation and evaluation of care supervision of nurses, nursing assistants, ancillary staff, collaborate with physicians, update care plans and medical recordsReimbursement CoordinatorMDS Minimum Data Sets, collect data from documentation and code the data for Medicaid, Medicare and private insurance billingStaff education on proper coding, financial reports, trending and analysis, scheduling and record keeping (PPS trackers)12/2011 - 7/2014Connolly /Now Cotiviti HealthCare, PA,Clinical Reimbursement AuditorMS-DRG, ICD-9 coding auditing, recovery auditing of provider charts, MDS RUG level reviews, appeals, and quality assurance, software: McKesson, 3MConcept development for RUGs and Home Health, application of InterQual, Millinium and CMS guidelines, education and training2/2010 - 10/2011Bryn Mawr Terrace, PADirector of Clinical Reimbursement/RNACMonthly clinical reimbursement reports, oversee Medicaid and Medicare end of month billing, picture date billing process, trending analysis reports, Utilization ReviewSupervision of 5 clinical reimbursement coordinators and two buildings, department budget management, CMS submissions2010 2011Towne Manor East Norristown, PAClinical Reimbursement ConsultantMDS auditing and audit weekly MDS submissions and in-service educationMonthly clinical reimbursement reports, Medicaid and Medicare end of month billing, picture date billing process, trending analysis reports and the monitoring of four buildings, oversea CMS submissions2000-2002Presbyterian Health Center, PAStaff RNNurse supervisor, clinical nursing, supervise staff, patient care1998 1999Evangelical Manor Nursing Home, PADirector of NursingManagement & supervision, quality assurance, planning and implementation of programs, development of policies & procedures, utilization review, staffing, managing and maintaining the nursing budgeting, staff counseling1995-1998Universal Consulting & Counseling Services, Inc., PAQuality Assurance NurseOversee all quality assurance functions, quality assurance audits, Medicare & utilization review audits, update policies, and procedures, quality assurance in-service educationContract AssignmentQuality assurance, utilization review using Interqual Criteria, credentialing and case management at HMA, BCBS and Jefferson University Hospital1994-1995Multi-Care Nursing Homes, NJRegional Nurse ConsultantChart audits, regulatory compliance audits, in-service education, quality assurance audits, Medicare & utilization review audits, update policy & procedure, in-service education, substitute DON1990-1998Home Staff Services/Kids Staff, PA(P/T, W/E & Holidays)Home Health NursePrivate duty nursing in patients home, wound care, respiratory, diabetic teaching and monitoring, medication management and prefill, Foley catheter insertions and maintenance, JP drains, IVs, injections, tube feedings, bolus feeds, Lovenox and B12, as well as insulin injections. Assessment, planning, implementation and evaluation of care, start of care, admissions, discharges.1999 -2002Member of Maple Village Board of Directors, Hatfield, PAEducation1999-2002 University of Maryland, University College, Adelphi, MDMajor: BusinessMasters Degree in Business Administration1989-1990 Pre Masters Program1990 to 1992 Masters Program in Human Services at Lincoln University, in Lincoln University PAMasters Degree in Human Services1984-1988 Wesley College, Dover, DEMajor: NursingAssociates Degree in Science of Nursing |
