Danica Warfield
Tampa,FL
Summary
Registered Nurse and Certified Case Manager (CCM) with fifteen years of expertise in Clinical Health Services and Managed Care operations. Background includes operational resource management, clinical program design & consulting, health informatics analysis, quality improvement, Complex CM/ DM, utilization management.
Overview
11
11
years of professional experience
1
1
Certification
Work History
High Complexity Case Manager
Blue Cross Blue Shield Of Minnesota
Tampa, FL
10.2018 - 02.2021
- Assessed physical, functional, social, psychological, environmental, learning and financial needs of members
- Identified problems, goals and interventions designed to meet member needs, including prioritized goals that consider member/caregivers goals
- Provided appropriate interventions which demonstrate knowledge of and sensitivity toward cultural diversity and religious, developmental, health literacy, and educational backgrounds of population served
Nurse Consultant & Disability Claims Supervisor
EXL Service/ MetLife
Tampa, FL
05.2018 - 09.2018
- Managed 50 direct reports: clinical & non-clinical staff
- Created policies, procedures and staff educational materials
- Trained, set goals and standards for job performance in accordance with Service Level Agreements (SLA)
Medicare Utilization Review Nurse
Integrated Resources Inc, Florida Blue
Jacksonville, FL
05.2017 - 04.2018
- Triaged, prioritized and reviewed standard and urgent requests for health-related services
- Determined medical necessity of requests by performing first level reviews using approved evidence-based guidelines/criteria
- Investigated medical claims to ensure appropriate coverage of services
Clinical Program Consultant
Aetna Inc
Jacksonville, FL
06.2015 - 04.2017
- Designed and developed clinical program interventions and facilitated work sessions to optimize achievement of strategic business objectives
- Analyzed health metrics and constructed reports/spreadsheets utilizing non-identifiable member data
- Subject matter expert (SME) for Aetna clinical programs
Case Management Team Lead
Aetna Inc
Jacksonville, FL
05.2012 - 06.2015
- Supervised day-to-day Case Management activities and performed program reporting to ensure adherence to URAQ and NCQA requirements
- Collaborated with account teams to manage potentially negative outcomes and to enhance
- Plan Sponsor relationships
- Executed medical and disability claim drill down for catastrophic claimant reports and monthly
- Plan Sponsor engagement meetings
Utilization Management Nurse Consultant
Aetna Inc
Linthicum Heights, MD
02.2008 - 10.2010
- Performed precertification review, admission review, concurrent retro review using Milliman Care
- Guidelines and Aetna Clinical Policy Guidelines
- Coordinated with facility Case Managers and Discharge Planners to ensure seamless transition of patients to appropriate level of care
- Authorized and coordinated required services in accordance with plan benefits
Education
Bachelor of Science - Nursing
Florida International University
05.2020
Associate Degree of Science - Nursing
Howard Community College
Columbia, MD12.2011
Skills
- EMR / EHR
- Documentation proficiency
- Treatment planning
- Direct Patient Care
- Staff education and training
- Staff Management
- Progress evaluations
- Patient Management
- Medical Records Management
- Interdisciplinary collaboration
- Shared governance
- Chronic disease management
- Patient Assessments
- Case management
- Interviewing skills
- Written and verbal communication
Certification
Certified Case Manager (CCM)
Registered Nurse (RN) / Florida / Minnesota
Timeline
High Complexity Case Manager
Blue Cross Blue Shield Of Minnesota
10.2018 - 02.2021
Nurse Consultant & Disability Claims Supervisor
EXL Service/ MetLife
05.2018 - 09.2018
Medicare Utilization Review Nurse
Integrated Resources Inc, Florida Blue
05.2017 - 04.2018
Clinical Program Consultant
Aetna Inc
06.2015 - 04.2017
Case Management Team Lead
Aetna Inc
05.2012 - 06.2015
Utilization Management Nurse Consultant
Aetna Inc
02.2008 - 10.2010
Bachelor of Science - Nursing
Florida International University
Associate Degree of Science - Nursing
Howard Community College