Angelica Zorana Gladney
Brandon
Summary
Dedicated Utilization Review and Case Manager Nurse with 16 years of experience in direct patient care and case management. Expertise in streamlining processes to enhance patient outcomes while ensuring regulatory compliance. Proficient in managing complex caseloads with a focus on Behavioral Health, Oncology, and Palliative Care, leveraging strong problem-solving skills and adaptability to meet diverse client needs. Committed to advancing organizational goals through effective resource management and a patient-centered approach. Proactive and versatile professional with a dedication to quickly adapting to new challenges. Strong problem-solving abilities and a proven track record of fostering strong relationships with clients and team members. Focused on supporting team success and achieving positive results.
Overview
13
13
years of professional experience
1
1
Certification
Work History
Medical Surgical Nurse/Charge Nurse/Oncology Nurse/ADT
Wake Forest Baptist Health High Point Medical Center
High Point
02.2017 - Current
- Facilitated multi-specialty patient care to achieve seamless service integration.
- Researched and delivered insights on infection prevention and patient safety.
- Guided critical care choices and worked with providers to ensure accurate treatment plans for severely ill patients.
- Applied critical thinking skills in emergent situations.
- Coordinated daily functions of a 30-bed medical-surgical unit to optimize workflow.
- Administered high-quality wound care to ensure optimal healing.
- Instructed on disease prevention methods, promoting healthier living.
- Enhanced post-operative pain management through evidence-based nursing interventions.
- Collaborated with healthcare professionals to address patient needs.
- Teamed up with various departments to pinpoint areas for process enhancement across the facility.
- Enhanced job satisfaction for nursing staff through strategic initiatives.
- Organized discharge plans encompassing detailed patient education.
- Directed clinical functions and monitored nursing team actions.
- Used computerized RPMS and EHR system.
- Collected lab specimens for diagnostic analysis.
- Monitored patient's respiration activity following medication administration.
- Addressed emergencies swiftly, applying expertise to deliver critical care.
- Strategized with physicians and clinical staff for treatment preparation.
- Offered emotional stability to patients and families facing challenging diagnoses.
- Recorded all treatments administered to patients as per hospital guidelines.
- Facilitated comfort for patients and families in challenging situations, enhancing recovery.
- Handled severe infusion reactions including fever, chills, nausea, vomiting, anaphylaxis and hypersensitivity.
- Created tailored care plans according to patient's physical, psychological, social and spiritual needs.
- Executed placement and removal of central venous catheters.
- Outlined discharge plans and post-op care requirements to families and patients.
- Worked jointly with physicians, social workers, and case managers to guarantee suitable patient placement.
Case Manager
North Carolina Community Health Care Association
Raleigh
06.2022 - 12.2024
- Evaluated and coordinated services to guarantee optimal outcomes, cost-effective care, and regulatory compliance.
- Facilitated member access to comprehensive clinical programs.
- Created personalized care strategies for patients dealing with intricate health conditions.
- Evaluated patient needs through telephonic outreach, providing referrals for mental health programs.
- Facilitated prior authorization requests and collaborated with healthcare providers to expedite approvals.
- Managed care transitions, including psychiatric bed placements, outpatient services, and long-term care options to ensure smooth transitions.
- Instructed on disease management, self-care, and community resources to enhance patient health.
- Managed documentation and communication with healthcare teams using EPIC, Greenway, and HEC.
- Handled the care coordination and management for a caseload of over 100 members with complex medical conditions.
- Defined and monitored SMART goals for team members to enhance progress.
- Leveraged health data analytics and clinical judgment to pinpoint at-risk members.
- Guided clients in understanding programs, benefits, and services.
- Recorded comprehensive data on cases, adhering to regulatory standards.
- Closely monitored cases, adjusting strategies as circumstances evolved.
- Completed comprehensive evaluations of clients' circumstances, pinpointing problems, objectives, and required actions.
- Optimized client-provider interactions via regular follow-ups.
- Delivered impactful solutions by designing effective case management plans.
- Actively engaged in team discussions, sharing insights to enhance client support strategies.
- Partnered with healthcare professionals, community organizations and agencies to deliver valuable client benefits effectively.
- Evaluated treatment plans based on individual goals.
Admission Discharge/Case Manager/Utilization Review Nurse
Forsyth Medical Center, Novant Health
Winston-Salem
05.2020 - 01.2021
- Evaluated clinical service requests to determine appropriate treatments.
- Coordinated with diverse professional teams to implement comprehensive patient care strategies.
- Reviewed prior authorization submissions to ensure proper handling.
- Ensured strict compliance with Utilization Management policies and procedures.
- Oversaw and managed all utilization review documentation using InterQual and MCG Health.
- Secured approvals from numerous insurance companies for diverse care levels.
- Educated medical staff on insurance protocols to enhance documentation accuracy.
- Ensured full compliance with both internal and external audit standards.
- Provided comprehensive information on care options, enhancing client decision-making.
- Closely monitored ongoing cases and adapted strategies when necessary.
- Ensured fair treatment of clients during interactions with external agencies.
- Actively participated in team discussions and case conferences, offering insights to optimize client support strategies.
- Facilitated useful benefits by collaborating with community organizations, agencies, and medical experts.
- Identified ways to enhance resource utilization for optimal patient care.
- Ensured prompt handling of at least 75 claims each month while maintaining seamless patient care by collaborating with medical and insurance professionals.
- Delivered crisis intervention support for clients in emergencies, employing effective techniques for safe de-escalation.
- Facilitated collaboration among interdisciplinary team members to meet patient needs.
- Coordinated efforts with health plan members, providers, case managers and stakeholders involved in patient care.
- Reviewed appeals submitted for denied claims per compliance guidelines.
- Analyzed insurance agreements concerning payment terms for services by providers.
- Oversaw adherence to prior authorization policies.
- Created standardized review processes and procedures compliant with state regulations.
- Evaluated clinical data from diverse sources, such as medical records and lab results.
Quality Assurance Auditor (QA2) - CNA Evaluator
Credentia
Bala Cynwyd
05.2019 - 05.2020
- Increased certification exam success by delivering tailored guidance.
- Conducted assessment sessions for groups of 15-20 students at certified locations.
- Formed collaborations with local healthcare providers to offer practical training resources.
- Incorporated state regulations and standards into course materials.
- Assessed student performance through evaluations to identify learning gaps.
- Analyzed educational resources regularly to assess improvements needed and modified them.
- Created safe learning conditions by enforcing rigorous training standards and equipment protocols.
- Conducted regular assessments of CNA skills and competencies.
- Assessed training programs for CNAs to ensure quality and effectiveness.
- Delivered feedback fostering CNA performance enhancement.
- Evaluate student performance during Pearson Review observation sessions in state-approved locations.
Behavioral Health Intake Nurse/Charge Nurse/Med-Psych Nurse/Utilization Review
Thomasville Medical Center, Novant Health
Thomasville
10.2016 - 04.2020
- Conducted comprehensive patient intake assessments covering mental health, physical, and psychosocial evaluations.
- Worked closely with diverse teams to facilitate seamless care delivery across the continuum.
- Evaluated service requests and clinical needs to ensure timely and cost-effective patient care.
- Assisted in crafting prior authorization requests for behavioral health treatments.
- Led nursing team by delegating tasks aligned with clinical needs and team skills.
- Provided education on mental health disease management, medication regimens, and therapeutic interventions.
- Evaluated clinical service requests to confirm medical appropriateness.
- Reviewed prior authorizations to assess member financial responsibility.
- Streamlined approval processes by ensuring access to needed care based on InterQual or MCG guidelines.
- Promoted behavioral health and long-term care for high-need members by adhering to InterQual and MCG guidelines.
- Referred relevant prior authorization requests to Medical Directors for final decisions.
- Oversaw operations of 45-bed Geri-psych medical-surgical floor.
- Conducted regular case conferences to assess client progress.
- Minimized hospital readmissions through meticulous case management.
- Built robust partnerships with community service providers to enhance client recovery outcomes.
- Adeptly supervised the care of 75+ patients, guaranteeing effective execution.
- Delivered comprehensive insights into mental health and substance abuse disorders to enhance awareness.
- Lowered healthcare expenses by optimizing resource allocation.
- Enhanced patient care quality through comprehensive utilization reviews.
- Evaluated patient conditions, observed behaviors, and reported updates to supervising physicians.
- Provided clear explanations of discharge plans to both patients and their families.
- Reviewed denial letters to assess adherence to timeliness standards.
- Enforced stringent patient data protocols to ensure HIPAA compliance.
- Facilitated group therapy sessions fostering support for individuals managing addiction and mental health issues.
- Provided counseling using evidence-based approaches for individuals facing depression or anxiety.
Case Manager/Home Health Nurse
Bayada Home Health
Winston Salem
12.2011 - 10.2018
- Oversaw home health care services encompassing discharge planning and post-hospitalization follow-up.
- Evaluated patient requirements, determining services necessary for optimal wellness at home.
- Worked collaboratively with healthcare teams to monitor patient progress.
- Guaranteed prompt handling of prior authorizations.
- Enhanced patient independence through education on self-care methods.
- Documented 40+ cases monthly, meeting regulatory standards and ensuring confidentiality.
- Informed clients about available programs, benefits, and services.
- Led to successful client outcomes through creation and execution of thorough case management plans.
- Promoted client rights during interactions with external agencies, fostering equitable treatment.
- Delivered critical support measures to manage client emergencies.
- Actively contributed to team discussions and case conferences.
- Collaborated with clinicians and support staff to create custom care plans.
- Evaluated client circumstances to identify problems and establish objectives.
- Informed clients and families about their rights.
- Recognized obstacles to client achievement and devised methods to surpass them.
- Oversaw caseloads efficiently with prompt documentation.
- Managed cases through intake, assessment and crisis intervention.
Charge Nurse-Licensed Practical Nurse
Pruitt Healthcare
High Point
12.2011 - 10.2015
- Enhanced patient satisfaction by promptly addressing concerns.
- Ensure a safe working environment through adherence to infection control policies.
- Worked with interdisciplinary teams to formulate comprehensive care plans.
- Oversaw daily scheduling, tasks, and administration.
- Managed medication administration, ensuring strict safety protocol adherence.
- Enhanced medication safety by implementing stricter administration protocols.
- Tailored care plans to align with each patient's specific needs and preferences.
- Worked alongside diverse healthcare teams to create tailored care plans for patients.
- Directed health campaigns, increasing community awareness.
- Documented patient information accurately to support informed decision-making.
- Mentored new nurses in correct techniques and care standards.
- Managed nursing care by assigning staff and facilitating doctor rounds.
- Provided direct quality care to a group of 45 patients.
- Served as a preceptor for new nurses by providing orientation to unit policies and procedures, coaching on clinical skills, and mentoring on professional development issues.
- Ensured compliance with HIPAA laws by maintaining strict patient data procedures.
- Participated in quality improvement initiatives to ensure best practice standards were met within the unit setting.
- Administered medications following strict safety protocols.
- Collaborated with administrator to assess patient care status.
- Compared patient results to defined care benchmarks.
- Adhered to OSHA regulations, ensuring workplace safety and cleanliness.
- Audited patient charts in real-time, verifying accuracy and completion of information.
- Coordinated with pharmacy, laboratory services, and physical therapy for accurate service delivery.
- Collaborated with interdisciplinary team to address patient needs.
Education
Bachelor of Science Degree - Nursing
Winston Salem State University
12.2021
Associate degree - Nursing
Davidson County Community College
05.2016
Licensed Practical -
Davidson County Community College
12.2010
Skills
- Quality assurance initiatives
- Knowledge of Medicare compliance standards
- Expertise in Medicaid compliance
- Utilization optimization
- Knowledge of InterQual guidelines
- Proficient in Milliman Care Guidelines
- Acute care expertise
- Technical documentation
- Analytical review of records
- Health insurance verification expertise
- Comprehensive patient care coordination
- Effective discharge strategy development
- Healthcare coordination expertise
- Health information technology expertise
- Comprehensive case oversight
- Compliance management
- Patient care utilization evaluation
- Case tracking management
- Multitasking proficiency
- Strategic policy deployment
- Exemplifies a positive professional attitude
- Meticulous attention to detail
- Fact analysis and compilation
- Cross-functional collaboration
- Quality assurance
- Prior authorization
Certification
- BLS for Healthcare Provider Certification
- Evergreen Certified Dementia Care Specialist
Timeline
Case Manager
North Carolina Community Health Care Association
06.2022 - 12.2024
Admission Discharge/Case Manager/Utilization Review Nurse
Forsyth Medical Center, Novant Health
05.2020 - 01.2021
Quality Assurance Auditor (QA2) - CNA Evaluator
Credentia
05.2019 - 05.2020
Medical Surgical Nurse/Charge Nurse/Oncology Nurse/ADT
Wake Forest Baptist Health High Point Medical Center
02.2017 - Current
Behavioral Health Intake Nurse/Charge Nurse/Med-Psych Nurse/Utilization Review
Thomasville Medical Center, Novant Health
10.2016 - 04.2020
Case Manager/Home Health Nurse
Bayada Home Health
12.2011 - 10.2018
Charge Nurse-Licensed Practical Nurse
Pruitt Healthcare
12.2011 - 10.2015
Bachelor of Science Degree - Nursing
Winston Salem State University
Associate degree - Nursing
Davidson County Community College
Licensed Practical -
Davidson County Community College
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