April Mefford
Bedford,KY
Summary
Experienced RN with strong case and care management background, specializing in effective utilization review and discharge planning. Demonstrated expertise at Anthem Medicaid KY. Proficient in EMR systems and passionate about patient advocacy. Improved care coordination and achieved exceptional nursing and patient outcomes.
Overview
13
13
years of professional experience
1
1
Certification
Work History
RN Case Manager II
Anthem Medicaid KY
11.2017 - Current
- Telephonic Post Discharge Case Management for Anthem Medicaid members
- Case Manager attempts to contact members telephonically, while still inpatient, or within three days of discharge from Inpatient status
- Assist Medicaid members with needs for durable medical equipment, financial resources for medical expenses, coordinating care in the home via home health
- Collaboration of care with primary care physicians and specialists for the member to have access to all resources available that may be needed during recovery
- Assist in Post Discharge Placement, if needed, by Skilled Nursing Facilities, Inpatient Rehabilitation Facilities or Long-Term Acute Care Facilities
- Work closely with Provider Relations/Contracting of plan to negotiate per diem rates for Skilled Nursing or Long-Term Acute Care admissions by Medicaid members
- Currently use GBD Facets and HIP for daily tasks
Nurse Medical Utilization Management
Anthem Medicaid KY
12.2016 - 11.2017
- Using my clinical knowledge to review pre-authorization requests for Anthem Medicaid members, to justify medical necessity for the procedure they are requesting
- Collaborating with member's healthcare providers to obtain necessary clinical information needed, to review these requested pre-authorizations
- Expected to maintain and build on education of current and future medical procedures, to make a clinical decision for medical necessity
- Knowledge of medical billing and coding, ICD-9 codes, procedure codes and of the billing process followed by Anthem
- Assist fellow nurses within the department with problem solving issues related to department process
Complex Case Manager
Humana Commercial Division
06.2015 - 12.2016
- Telephonic Case Management for Humana Commercial members including Affordable Care Act plan holders
- Complex Case Manager contacts members telephonically, within 24 to 49 hours of discharge from Inpatient status
- Assisted commercial Humana members with needs for durable medical equipment, financial resources for medical expenses, coordinating care in the home via home health
- Collaboration of care with primary care physicians and specialists for the member to have resources to all available resources that may be needed during recovery, from scheduled or emergency procedures
- Care planning for commercial member's complex needs, and frequent telephonic contact with members until full recovery, or until all complex needs are met
Clinical Nurse Advisor/Utilization Management
Humana
05.2013 - 06.2015
- Using my clinical knowledge to review pre-authorization requests from Humana Medicare members, to justify medical necessity for the procedure they are requesting
- Collaborating with member's healthcare providers to obtain necessary clinical information needed, to review these requested pre-authorizations
- Expected to maintain and build on education of current and future medical procedures, to make a clinical decision for medical necessity
- Working with process managers on enhancing procedure processes within the department, to simplify the process of reviewing requested medical procedures
- Collaborating with senior Medicare members and educating them on processes required for managing their healthcare coverage, as well as educating them on Humana's expectation of them as a member of Humana managed Medicare
- Knowledge of medical billing and coding, ICD-9 codes, procedure codes and of the billing process followed by Humana
- Involved in training of newly hired nurses within the Clinical Intake department
- Assist fellow nurses within the Clinical Intake department with problem solving issues related to department process
- Assist with processing of clinical reviews that need manual claims, due to downtime of technical components (Downtime Process Contact for CIT Louisville)
- Involved with a selected group of nurses for creation of new procedures related to nurse’s autonomy processes within the Clinical Intake department for Louisville CIT as well as Green Bay, New Orleans, and San Antonio locations
- As a part of the Clinical Intake team, I enjoy offering my input and volunteering to accept new roles within the department, to expand my knowledge of the Clinical Intake department and processes
Home Health Nurse I/Case Manager
Three Rivers District Health Department
07.2012 - 05.2013
- Case management of all aspects of care for several Home Health Patients in 5 counties; including Nursing needs, Therapy needs and providing supplies to patients needed for wound care as well as any other supplies needed while under care with Agency
- Providing nursing care/skills that are specific to each patient and within RN scope of practice
- Working with all disciplines involved in patient care to coordinate best care possible for the patient
- Computer charting on each visit with a patient as well as knowledge of Medicare laws and regulations that must be followed to insure proper payment for services
RN Staff Nurse
Cedar Lake Lodge
02.2012 - 07.2012
- Medication and Treatment administration, Wound Care, all types of injections, IV therapy, Gastric Tube medication administration and care, IV insertion and administration of IV medications
- Assisting mentally challenged residents with all aspects of daily living and wellbeing
- Administration of physician orders ensuring accountability and accuracy of resident care for the facility to obtain funding to continue current level of care or change care as needed
- Involvement in Quality assurance issues to ensure all residents receive the highest quality of care
- Assisting with specialty clinics at facility for the residents to receive all levels of care such as Dental, Gastrointestinal, Hearing, Sight, Allergy issues, Neurological, Physical Therapy, Occupational therapy
- Specialize in residents who are mentally disabled and able to recognize seizure activity on all levels
- Care Planning for Residents
- Knowledge of Medicare regulations and ICD-9 codes
- Involved in opening of new facility within the Cedar Lake Corporation, as a staff nurse
- Assisted the Director of Nursing with initiation of new departments within this new establishment, for the facility to operate according to state regulations
Education
BSN - Nursing Licenses
Indiana Wesleyan University
Marion, INSkills
- RN
- Case Management
- Utilization Review
- Home Health
- Care Management
- Home Care
- InterQual
- Hospital
- Utilization Management
- Nursing
- Tube Feeding
- Medication Administration
- Intake Experience
- EMR Systems
- ICD-9
- Medical Records
- Medical Billing
- Clinical assessment
- Medication Management
- HIPAA Compliance
- Utilization review
- Discharge Planning
- Care Coordination
- Insurance knowledge
- Documentation
- Acute and rehabilitative care
- Compassionate and Caring
- Heartsaver First Aid (First Aid)
- Intake and discharge
- Problem-Solving
- Clinical Documentation
- Time Management
- Effective Communication
Certification
- BLS
- ACLS
Personal Information
Work Permit: Authorized to work in the US for any employer
Nursinglicenses
RN
References
References available upon request.
Timeline
RN Case Manager II
Anthem Medicaid KY
11.2017 - Current
Nurse Medical Utilization Management
Anthem Medicaid KY
12.2016 - 11.2017
Complex Case Manager
Humana Commercial Division
06.2015 - 12.2016
Clinical Nurse Advisor/Utilization Management
Humana
05.2013 - 06.2015
Home Health Nurse I/Case Manager
Three Rivers District Health Department
07.2012 - 05.2013
RN Staff Nurse
Cedar Lake Lodge
02.2012 - 07.2012
- BLS
- ACLS
BSN - Nursing Licenses
Indiana Wesleyan University
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