ANDREA RINK-ELLIOTT

Stop Loss Nurse Reviewer (May 2023-Present)

• Created and developed guidelines for process improvement
• Composed Electronic Desktop References to streamline tasks
• Collaborated and constructed Preferred Client forms and Multiple Member request forms to enhance workflow
• Reviewing cases using multiple systems, accesses pertinent data sources and answers proposed clinical questions from Executive inquires
• Addressing and supporting Stop Loss with high-cost claimants (H.C.C.) by identifying high-cost medications, new diagnosis and future treatment plan for gene therapy and transplants
• Reviewing and auditing cases of HCC and referring over to Health Coach for proactive cost-savings
• Skilled at document formatting
• Worked collaboratively on training manual and created original templates with user guides for new employees
• Special projects: Working interdepartmentally with Risk Analysis Department developing reports on high-cost claimants to assist the underwriters
• Ownership of New Hire License Verification TPA 11/2024
• Assisted with Policy preparation for NCQA renewal 9/2024
• Participated in professional development classes: Mentor-mentee program 6/2024

Nurse Case Manager (August 2015-May 2023)
• Provided excellent customer services to our TPA self-funded and funded customers at the local and national levels
• Responsible for assessing and determining member need and eligibility for case management
• Provide coaching and evidence-base practice to assist family members with self-management and preventative care strategies of their medical and disease process
• Acted as primary point of contact for clients and their families, helping them navigate healthcare services, insurance coverage and treatment options
• Analyzed patient outcomes and continuously re-evaluated care plan and documented accordingly
• Research and provide resources available to members based on their specific needs
• Evaluated and authorized medical necessity for various types of reviews, utilizing the InterQual criteria and established medical policies and procedures. Submit cases to the Medical Director for review, ensuring compliance with InterQual guidelines
• Participated in complex bi-monthly rounds
• Collaborate with healthcare providers to ensure medically necessary treatments were provided and properly documented for reimbursement along with seamless transition of care
• Crafted reports to Co-Marketing groups and large case notices for high-cost claimants
• Mentoring and training new case managers and staff, providing training on case management best practices, clinical protocols and patient care processes and sharing homegrown templates for successful audit scores
• Participated in The Blue Crew, EDR and Case Management (C.M.) committees, taking ownership of CM committee policy and reviewer processes. Managed utilization management reviews and determinations, and addressed pharmacy call outs for ‘refills too soon' issues
• Developed a Quick Reference Guide to improve engagement in Disease Management (D.M.)
• Assisted in conducting interviews for prospective Case Managers
• Participated in professional development classes: Future Blue Leaders, Developing your brand, Powerless to Powerful seminars

Emergency Trauma Center, Progressive Care Unit, and Medical/Surgical Unit/Hospice Nurse

• Emergency Room Nurse