PROFESSIONAL EXPERIENCE:

Confidential

Contract RN Case Manager

Responsibilities:

• Provides case management, care coordination, and disposition planning.
• Identify high risk patients and refer to Social Work.
• Conduct Initial Assessments to develop plan of care.
• Ensure that treatment plan is implemented, re - evaluated and updated daily.
• Facilitate effective communication between members of the treatment team.
• Facilitate/participate in daily huddles.
• Active role as an advocate for the patient/family.
• Monitor LOS daily and identify barriers to discharge.
• Maintain accountability for facilitating clinical patient progression through a defined plan of care to achieve optimal outcomes.
• Perform admission, concurrent, and retrospective reviews on patients as needed.

Confidential

Contract RN Case Manager

Responsibilities:

• Provides case management, care coordination, and disposition planning.
• Assists service members and/or veterans and family members with receiving the most appropriate options and services to meet their complex health care needs. This includes, but is not limited to, acute, chronic, multiple, complex, catastrophic, or life-threatening illnesses; combat stress, residuals of traumatic brain injury; community adjustment; addictions; and other health problems.
• Coordinates care with multiple providers across all levels and sites of care.
• Addresses psychosocial as well as nursing and medical needs of patients and their families through participation in multidisciplinary patient care management practice.
• Evaluates care and outcomes to ensure timely and appropriate provision of services.

Confidential

Case Manager/Utilization Review/Part

Responsibilities:

• Performs utilization review in accordance with all state mandated regulations using InterQual® Level of Care Criteria.
• Maintains compliancy with regulation changes affecting utilization management.
• Reviews patients’ records and evaluates patient progress.
• Performs continuing review on medical records and identification and need of on-going hospitalization.
• Obtains and reviews necessary medical reports and subsequent treatment plans to assure proper patient status; inpatient versus outpatient.
• Reviews and validates physician’s orders, reports progress, and unusual occurrences on patients.
• Ensures appropriate and cost-effective healthcare services to patients.
• Analyzes patient records, and participates in interdisciplinary collaboration with professional staff.
• Provides discharge planning to patients and families.
• Coordinates transfers to extended care facilities (ECF), group care homes, or other acute hospitals as appropriate.
• Documents discharge plan in medical record, completing final documentation within two working days of discharge.
• Functions as a member of a multidisciplinary case management team.
• Participates fully as a member of the social services department.

Confidential

Clinical Appeals Coordinator

Responsibilities:

• Responsible for managing client medical denials by conducting a comprehensive analytic review of clinical documentation to determine if an appeal is warranted.
• When an appeal is warranted, prepare convincing appeal arguments using pre-existing criteria sets and/or clinical evidence from existing library of clinical references and/or regulatory arguments.
• Search for supporting clinical evidence to support appeal arguments when existing resources are unavailable.
• Proficiently read and understand abstract information from handwritten patient medical records.
• Ensure compliance with HIPPA regulations, to include confidentiality, as required.

Confidential

Travel Nurse/Utilization Review

Responsibilities:

• Performs utilization review in accordance with all state mandated regulations using InterQual® Level of Care Criteria.
• Maintains compliancy with regulation changes affecting utilization management.
• Reviews patients’ records and evaluates patient progress.
• Performs continuing review on medical records and identification and need of on-going hospitalization.
• Obtains and reviews necessary medical reports and subsequent treatment plans to assure proper patient status; inpatient versus outpatient.
• Reviews and validates physician’s orders, reports progress, and unusual occurrences on patients.
• Ensures appropriate and cost-effective healthcare services to patients.
• Analyzes patient records, and participates in interdisciplinary collaboration with professional staff.

Confidential

Travel Nurse/Case Management

Responsibilities:

• Performs utilization review in accordance with all state mandated regulations using InterQual® Level of Care Criteria.
• Maintains compliancy with regulation changes affecting utilization management.
• Reviews patients’ records and evaluates patient progress.
• Performs continuing review on medical records and identification and need of on-going hospitalization.
• Obtains and reviews necessary medical reports and subsequent treatment plans to assure proper patient status; inpatient versus outpatient.
• Reviews and validates physician’s orders, reports progress, and unusual occurrences on patients.
• Ensures appropriate and cost-effective healthcare services to patients.
• Analyzes patient records, and participates in interdisciplinary collaboration with professional staff.
• Provides discharge planning to patients and families.
• Coordinates transfers to extended care facilities (ECF), group care homes, or other acute hospitals as appropriate.
• Documents discharge plan in medical record, completing final documentation within two working days of discharge.
• Functions as a member of a multidisciplinary case management team.
• Participates fully as a member of the social services department.

Confidential

Clinical Appeals Nurse

Responsibilities:

• Reviews Medical Documentation to determine medical necessity for inpatient level of care as well as outpatient procedures.
• Writes appeal letters to payers when medical documentation confirms medical necessity of denied claim.
• Reviews accounts for billing, payments, medical records received, and write offs.
• Identify coding or clinical documentation issues and work to correct the errors in a timely manner.
• Identify problem accounts and escalate as appropriate.
• Update the patient account record to identify actions taken on the account.
• Other duties as assigned.

Confidential

Travel Nurse/Case Management

Responsibilities:

• Performs utilization review in accordance with all state mandated regulations using InterQual® Level of Care Criteria.
• Maintains compliancy with regulation changes affecting utilization management.
• Reviews patients’ records and evaluates patient progress.
• Performs continuing review on medical records and identification and need of on-going hospitalization.
• Obtains and reviews necessary medical reports and subsequent treatment plans to assure proper patient status; inpatient versus outpatient.
• Reviews and validates physician’s orders, reports progress, and unusual occurrences on patients.
• Ensures appropriate and cost-effective healthcare services to patients.
• Analyzes patient records, and participates in interdisciplinary collaboration with professional staff.
• Provides discharge planning to patients and families.
• Coordinates transfers to extended care facilities (ECF), group care homes, or other acute hospitals as appropriate.
• Documents discharge plan in medical record, completing final documentation within two working days of discharge.
• Functions as a member of a multidisciplinary case management team.
• Participates fully as a member of the social services department.

Confidential

Travel Nurse/Utilization Review

Responsibilities:

• Performs utilization review in accordance with all state mandated regulations using InterQual® Level of Care Criteria.
• Maintains compliancy with regulation changes affecting utilization management.
• Reviews patients’ records and evaluates patient progress.
• Performs continuing review on medical records and identification and need of on-going hospitalization.
• Obtains and reviews necessary medical reports and subsequent treatment plans to assure proper patient status; inpatient versus outpatient.
• Reviews and validates physician’s orders, reports progress, and unusual occurrences on patients.
• Ensures appropriate and cost-effective healthcare services to patients.
• Analyzes patient records, and participates in interdisciplinary collaboration with professional staff.

Confidential

Seasonal Influenza Nurse Administrator

Responsibilities:

• Contacting client clinic coordinator to confirm: directions to clinic, anticipated number of participants, vaccine allocation - flu, FluMist, pneumonia, logistics for specific clinic.
• Pick-up and return of all supplies required to conduct clinic: vaccine, forms - consents, receipts, special consents, medical supplies, clinic cash/checks balanced to vaccines administered.
• Patient assessment prior to vaccine administration.
• Prepare on-site clinic areas for services - vaccines and paperwork.
• Documentation: consent forms completed by patient prior to vaccine administration, nurse signature on consents, receipts and sign in forms, balanced sign in sheet for reconciliation.
• Vaccine and supply inventory: inventory tracking and variance reporting, in-depth knowledge of all vaccines administered.
• Passport Health nursing protocols and best practices: comply with standard Passport Health protocols.
• Performs utilization review in accordance with all state mandated regulations using InterQual® Level of Care Criteria.
• Maintains compliancy with regulation changes affecting utilization management.
• Reviews patients’ records and evaluates patient progress.
• Performs continuing review on medical records and identification and need of on-going hospitalization.
• Obtains and reviews necessary medical reports and subsequent treatment plans to assure proper patient status; inpatient versus outpatient.
• Reviews and validates physician’s orders, reports progress, and unusual occurrences on patients.
• Ensures appropriate and cost-effective healthcare services to patients.
• Analyzes patient records, and participates in interdisciplinary collaboration with professional staff.

Confidential

Disability Specialist III/Nurse Consultant

Responsibilities:

• Analyzes, approves, and authorizes assigned claims and determines benefits due pursuant to a disability plan.
• Medically manages disability claims ensuring compliance with duration control guidelines and plan provisions.
• Communicates clearly with claimant and client on all aspects of claims process either by phone and/or written correspondence.
• Informs claimants of documentation required to process claims, required time frames, payment information, and claim status either by phone, written correspondence, and/or claims system.
• Evaluates and arranges appropriate referral of claims to outside vendors for surveillance, independent medical evaluation, functional capability evaluation, and/or related disability activities.
• Maintains professional client relationships.
• Maintains a quality assurance program to support the total performance management initiative and the consistent delivery of quality claims service.
• As a consultant, assisted non-medical examiners in reviewing medical documentation and advising on the next course of action, reviewed the IME (independent medical evaluation) reports and PA (physician advisory) reviews for accuracy and completeness to determine if claimant is disabled.
• Assisted new examiners with help in all matters of disability management including use f Juris program.

Confidential

Private Duty Pediatrics

Responsibilities:

• Provided in home care of Confidential with special needs including trach, vent, O2 therapy, respiratory treatments, tube feedings, suctioning, etc.
• Maintained patient records of visit with high standard of excellence.
• Provided direction and assistance to the family.
• Education of family in the care of new treatments, medications, etc.

Confidential

RN Case Manager

Responsibilities:

• Functioned as a member of a multi-disciplinary team for outpatient hospice patients.
• Responsible for providing nursing expertise and ensuring all services needed are identified, outlined in the Plan of Care and delivered to hospice patients and family members.

Confidential

RN Case Manager

Responsibilities:

• Works with the members of the health care team to ensure coordination of optimal healthcare across the continuum for patients and their families.
• Utilizes good interpersonal relationships with all third party payers, vendors, outside. agencies and all professionals to collaborate optimal care along the continuum
• Patient advocate by providing access to treatment programs and specialty care centers through communication with family, team members and community health care providers.
• Assesses and/or participates in the identification of age and culturally appropriate educational and resource needs.
• Communicates and participates in problem solving of clinical and quality assurance issues, utilizing physician and nursing advisors as needed.
• Ensures that all regulatory requirements for governmental programs are met.
• Acts as a facilitator of the discharge planning process across the continuum of care, including documentation of discharge plan in the medical record/computer.
• Interfaces with third party payers according to established criteria in order to maximize reimbursement.

Confidential

RN Case Manager

Responsibilities:

• Contract assignment at Confidential ’s Confidential - Case Management Dept.
• Facilitates and assures coordination of optimal healthcare across the continuum for patients and their families.
• Utilizes good interpersonal relationships with all third party payers, vendors, outside agencies and all professionals to collaborate optimal care along the continuum.
• Patient advocate by providing access to treatment programs and specialty care centers through communication with family, team members, and community health care providers.
• Assesses and/or participates in the identification of age and culturally appropriate educational and resource needs.
• Communicates and participates in problem solving of clinical and quality assuranceissues, utilizing physician and nursing advisors as needed.
• Ensures that all regulatory requirements for governmental programs are met.
• Acts as a facilitator of the discharge planning process across the continuum of care, including documentation of discharge plan in the medical record.
• Interfaces with third party payers according to established criteria in order to maximize reimbursement.

Confidential

RN, Case Manager

Responsibilities:

• DOD Contract assignment at Confidential, GA for the med hold battalion.
• Functioned as a member of a multi-disciplinary team by coordinating and implementing a patient care plan per a care provider.
• Actively monitored and evaluated case manager options and services to meet anindividual’s health needs through proactive communication and proactive use of medical resources to efficiently promote quality outcomes.
• Specifically, in the setting of medical holdover clinic at Confidential, GA, this encompassed the following:
• Rapid interview and processing of consults within Commander’s intent upon initial visit.
• Ensuring that MD notes are fully reviewed and disposition plans are clear.
• Revise disposition plans as needed in conjunction with the soldier’s provider.
• 4. Complete initial data collection, real time entry and updating in MODS and
• MCCS databases, and thorough documentation in case manager files.
• Developed and implemented data base for soldiers needing care prior to deployment to Iraq.
• Maintained high standards of excellence.
• Assisted subordinates and supervisors in identifying and resolving problems.
• Contributed to all aspects of daily clinic operation.
• Trained new case managers in all aspects of job requirements.
• Demonstrated effective leadership and encouraged team concepts.