Aqueelah Beyah-Muhammad
Health Plans UM Nurse- Seeking Immediate Hire
Marietta,Georgia
Summary
Results-driven healthcare operations professional with over 30 years of experience ensuring compliance with internal and government standards across diverse healthcare settings. Proven track record in effectively managing teams while delivering exceptional results and exceeding organizational goals. Expertise in data analysis, time management, trend tracking, and troubleshooting, complemented by a strong aptitude for building collaborative relationships within multidisciplinary teams. Recognized for exceptional communication skills and a creative approach to project planning and execution, consistently fostering positive environments and driving successful outcomes.
Overview
20
20
years of professional experience
4
4
Certificates
3
3
Languages
Work History
Supervisor/ Utilization Management Nurse
Sonder Health Plans
Marietta, GA
11.2024 - Current
- Managed 8-10 coordinators- managing over 50 customer calls each/per day. Decreasing complaints up to 10%- 15% in one quarter.
- Identify member risk and/or quality concerns and report these to the appropriate resources.
- Provide leadership for and present during Integrated Health Services meetings and member rounds.
- Conduct regular audits to ensure data entry and integrity.
- Identify opportunities for process improvement and efficiency in health service coordinator and utilization management functions.
- Provide training and support to new team members and continued training, when needed, to existing team members.
- Develop membership educational materials.
- Collaborate with medical staff to resolve any concerns or issues.
- Maintain a high level of accuracy and attention to detail.
- Communicate effectively with team members and stakeholders.
- Generate reports based on quantitative and qualitative analysis.
- Adapt to new software and technologies and assist team in the use of software and technologies including entering and maintaining assessments, care plans, and other pertinent clinical documentation and information into various medical management systems.
- Collaborate with and coordinate services and support between the Primary Care Physician (PCP), specialists, medical, behavioral, and community/social service providers, as well as other key interdisciplinary team members to meet the complete medical and social needs of members and the team.
- Monitor and document all member referrals to support the member’s overall care plan and ensure the member receives needed/requested services or support assisting team members as needed.
- Other duties as assigned.
- Prioritize and organize workload to meet deadlines.
- Uphold the company’s values and ethical standards in all interactions.
- Oversaw daily operations of the department, ensuring smooth workflow and timely completion of tasks.
- Applied strong leadership talents and problem-solving skills to maintain team efficiency and organize workflows.
Nurse Case Review Specialist/ Revenue Cycle Utilization Management/ Denial Management
Northside Hospital
07.2019 - 11.2024
- Successful analysis of excel spreadsheets for 5 campuses, ensuring the authorizations, denials management, back billing, and compliance of Medicaid and Humana cases.
- Successful analysis of outliers for 5 campuses ensuring compliance to Medicaid and Care Management Organizational guidelines for appropriate Level of Care, Intensity of services, and billing.
- Cerner Health Information Management system application, monitor, and management of clinical data.
- Analyzed complex data sets, providing valuable insights for decision-making purposes.
- Served as a subject matter expert on various projects, providing valuable input towards achieving project objectives in a timely manner.
- Managed a high volume of reviews within tight deadlines, ensuring timely completion and client satisfaction.
- Conducted thorough evaluations for better compliance and risk mitigation.
- Collected and analyzed information to monitor compliance outcomes and identify and address trends of non-compliant behavior.
- Reviewed high-priority cases with heightened attention to detail, mitigating potential risks associated with non-compliance issues.
- Successfully managed multiple competing priorities, balancing workload and ensuring consistent delivery of high-quality reviews.
- Maintained up-to-date knowledge on industry trends and regulations, providing informed guidance to colleagues and clients alike.
- Identified areas of improvement in operational workflows, leading to increased productivity and reduced errors.
- Promoted a positive work environment by facilitating open discussions and encouraging feedback from team members.
- Leveraged technology to enhance review processes, resulting in time savings and improved accuracy rates.
Nurse Case Review Specialist/ Special Care Nursery/NICU/High Risk Pregnancy- Coordination
Northside Hospital, Atlanta Campus, Special Care Nursery/ NICU
03.2015 - 07.2019
- Successfully managing daily utilization reviews, discharge plans (as developed/ approved by Care Coordinator), Issues Notice of Non-coverage letters concerning transfer to private pay in accordance with hospital policy and Medicare and third-party payor guidelines.
- Improved accuracy rates by 20%
- Improved approval rates for complex case management by 15%
- Discuss financial responsibility issues with medical staff, patient and family members as appropriate.
- Carry out plan-of-care (as developed/ approved by the case manager), including making calls for discharge referrals, follow-up on patient education, patient community resources, and as requested by Care Coordinator.
- Performed accurate documentation of patient assessments, interventions, and outcomes in compliance with regulatory standards.
- Collaborated with interdisciplinary teams for optimized patient treatment plans and outcomes.
- Evaluated existing procedures against regulatory requirements, identifying gaps and recommending improvements where necessary.
- Contributed to continuous improvement initiatives by participating in process assessments and offering actionable suggestions for enhancement opportunities.
- Collaborated with cross-functional teams to improve overall review efficiency and effectiveness.
- Established strong relationships with clients, addressing concerns promptly and maintaining open lines of communication.
- Managed a high volume of reviews within tight deadlines, ensuring timely completion and client satisfaction.
Utilization Management Nurse/ Medicare Utilization Nurse
Aetna/Coventry Healthcare of Georgia
11.2012 - 03.2015
- Successfully applied critical thinking towards best practice, individual patient continuum of care outcomes based on, clinical data, clinical judgment, and appropriate coverage.
- Reviewed over 25-30 cases daily.
- Improved accuracy rates by 20%
- Improved successful management of the discharge planning review process, improving overall clinical outcomes for members at an increased 35%.
- Successfully managing Aetna/Coventry merger: Clinical data and Information Systems More specifically, the utilization management obtains information and applies appropriate clinical criteria, guidelines, and clinical judgment to render appropriate coverage determination and recommendations along a continuum of care; communicates with providers to facilitate appropriate treatment; identifies members for referral opportunities for internal and external services; identifies opportunities to promote quality of services and proper utilization of benefits.
- Maintained up-to-date knowledge of payer-specific guidelines to ensure accurate authorizations for medically necessary services.
- Provided exceptional patient advocacy through active listening, empathy, and support during challenging situations.
- Applied critical thinking skills to assess complex medical cases and determine appropriate levels of care in accordance with industry benchmarks.
- Facilitated communication between healthcare providers, patients, families, and insurance carriers to optimize outcomes.
- Improved patient satisfaction scores by providing timely and accurate information on coverage, benefits, and authorization requirements.
- Contributed to team success by consistently meeting productivity goals while maintaining high-quality standards in job performance.
- Coordinated seamless transitions of care across multiple settings including acute care hospitals, rehabilitation facilities, and home care services.
Admissions Director
Manor Care of Decatur Nursing and Rehabilitation
04.2012 - 11.2012
- Successfully increased facility census and quality mix of the nursing facility.
- Successfully developed monthly and annual marketing budgets and plans.
- Successfully marketed, as a Nurse Liaison, to external physicians, and hospitals- increasing referral sources, and facility notoriety while driving up census; Including on-site visits (to over 5 hospitals and various community sources), facility-community based events, daily sales calls, face-to-face visits -building relationships while securing and obtaining a steady flow of referrals (referral sources).
- Advised applicants on prospects for admission and strategies for meeting academic and extracurricular credentials.
- Served as primary contact for coordination of application screening and tracking, visit and interview arrangement and marketing communications.
MDS Coordinator/ Nurse Manager
Manor Care of Decatur Nursing and Rehabilitation
07.2009 - 04.2012
- Achieved promotion to Admissions Director
- Achieved 95-100% departmental compliance with JACHO annual surveys.
- Successfully assisted in coordinating Resident Assessment Instruments (RAI), Care Area Assessments (CAA), and Care Plans- while maintaining federal mandated required guidelines, facilitating a functioning interdisciplinary team, accurate reporting of Resource Utilization Group System (RUGS) to all departments, maintaining Roster and Census reports, and monitoring of all reports generated by this department.
- Optimized care plans for impact, integrating evidence-based practices and patient preferences.
- Promoted culture of safety and compliance, conducting regular audits of Minimum Data Sets (MDS) documentation and care practices.
Case Manager
UHS Pruitt - Corporate Office
10.2008 - 07.2009
- Successfully coordinated and managed individual case loads of 14 UHS Rehabilitation facilities in Georgia.
- Successfully completed medical necessity reviews, pre-certification of hospitalizations, level of care (LOC) negotiation/determinations, while focusing on cost-efficient-best practices for optimal continued healthcare desired outcomes.
- Educated clients on available programs, benefits, and services, empowering them to make informed decisions about their care needs.
- Conducted thorough assessments of clients'' situations, identifying issues, goals, and necessary interventions.
MDS Coordinator/ Nurse Manager
Roswell Nursing and Rehabilitation
09.2006 - 10.2008
- Achieved 90-100% improved JACHO compliance satisfaction scoring during tenure, by coordinating resident assessments (admission, quarterly, annually, significant change), RAI, RAPS and Care Plans-timely.
- Daily management meetings of the interdisciplinary team-providing accurate reporting of RUGS to all departments, Roster and Census reports, and monitoring of all reports generated by MDS department.
- Facilitated smooth transitions of care by collaborating with external healthcare providers, ensuring continuity of care for residents.
- Monitored changing regulations related to RAI/MDS requirements, keeping staff informed about updates that impact their daily work routines.
Patient Educator /Acute Disease Manager
Matria Healthcare
03.2006 - 08.2006
- Patient educator: Focus- Wellness, and Education
- Achieved placement on specialty teams focused on high-level accounts, in addition to multiple bonuses because of 90-100% satisfaction and patient enrollment in continuing disease-specific education programs.
- Collaborate with Workmen’s Compensation on qualitative and quantitative progression of members health progress and report information to the organization. Weekly meetings with Risk Management regarding current standing SOP’s. Assisted in SOP revision.
- Facilitated group workshops on various health topics, enhancing peer support and shared learning experiences among participants.
- Improved patients'' adherence to treatment plans through clear explanations and demonstrations of procedures.
Education
Doctor of Healthcare Administration (c-DHA) - Healthcare Administration And Management
University of Phoenix
Phoenix, Arizona12.2023
MBA - Health Informatics Certification (HIT), Marketing
University of Phoenix
Phoenix, Arizona 05.2001 -
Master of Healthcare Administration - Healthcare Leadership And Sustainability
University of Phoenix
Tempe, AZ 05.2001 -
Bachelors Healthcare Administration - Healthcare Administration Policies And Finances
University of Phoenix
Sandy Springs, Georgia06.2011
Skills
Project management
Healthcare information systems expertise
Team leadership
Process improvement
Strategic planning
Operations management
Staff management
Accomplishments
- Used Microsoft Excel to develop inventory tracking spreadsheets.
- Achieved Increased Physician collaboration through effectively helping with process improvement between clinical providers and insurance companies- Improving compliance and case review denial management.
Affiliations
- American Nurses Association
- ACHCA- American College of Health Care Administrators
- HIMSS- Health Information Management Systems
- Modern Healthcare HITS
- National Society of Leadership and Success (NSLS) - Leadership Builders
Certification
LPN Licensure (Current- Expiration 3/2027)
Timeline
BLS/ACLS Certified: Advanced/Current - Expires 2027
10-2027
LPN Licensure (Current- Expiration 3/2027)
03-2027
Supervisor/ Utilization Management Nurse
Sonder Health Plans
11.2024 - Current
Nurse Case Review Specialist/ Revenue Cycle Utilization Management/ Denial Management
Northside Hospital
07.2019 - 11.2024
Nurse Case Review Specialist/ Special Care Nursery/NICU/High Risk Pregnancy- Coordination
Northside Hospital, Atlanta Campus, Special Care Nursery/ NICU
03.2015 - 07.2019
Utilization Management Nurse/ Medicare Utilization Nurse
Aetna/Coventry Healthcare of Georgia
11.2012 - 03.2015
Admissions Director
Manor Care of Decatur Nursing and Rehabilitation
04.2012 - 11.2012
MDS Coordinator/ Nurse Manager
Manor Care of Decatur Nursing and Rehabilitation
07.2009 - 04.2012
Case Manager
UHS Pruitt - Corporate Office
10.2008 - 07.2009
MDS Coordinator/ Nurse Manager
Roswell Nursing and Rehabilitation
09.2006 - 10.2008
Patient Educator /Acute Disease Manager
Matria Healthcare
03.2006 - 08.2006
MBA - Health Informatics Certification (HIT), Marketing
University of Phoenix
05.2001 -
Master of Healthcare Administration - Healthcare Leadership And Sustainability
University of Phoenix
05.2001 -
Doctor of Healthcare Administration (c-DHA) - Healthcare Administration And Management
University of Phoenix
Bachelors Healthcare Administration - Healthcare Administration Policies And Finances
University of Phoenix