Ashley Raddish
Morgantown
Summary
Registered Nurse with over 4 years of experience in utilization and medical management, alongside 3 years of experience in case management and acute care. Proficient in collaborating with physicians to provide high-quality, cost-effective patient care. Demonstrates excellent written and oral communication skills, complemented by a strong understanding of federal and state laws, as well as NCQA regulations related to utilization management. Committed to ensuring optimal patient outcomes through effective care coordination and management.
Overview
11
11
years of professional experience
Work History
Nurse Medical Management
Wellpoint | Elevance Health
03.2021 - Current
- Review requests and determine medical necessity for concurrent or retrospective admissions to for hospital setting
- Review requests for predeterminations for LTAC, AIR and hospice admissions
- Conduct continued stay reviews for high length of stay, high dollar, complex cases
- Discharge planning for complex needs, identify discharge need or barriers for members who are at high risk for readmissions and make appropriate referrals
- Work closely with medical directors to determine appropriateness of medical services requested and received
- Subject matter expert for case management/ utilization management collaboration
Registered Nurse Case Manager
Elevance Health
07.2019 - 03.2021
- Nurse Case Manager for Post Discharge Management program
- Manage members complex and chronic care needs by assessing, developing, implementing, coordinating and evaluating care plans designed to optimize member’s health care across care continuum
- Conduct assessments to identify individual needs and coordinate internal and external resources and education to meet identified needs
- Collaborate with social workers, behavioral health team and plan Medical Director to meet needs of members
- Participate in collaborative work groups to identify workflow efficiency ideas and implement as necessary
Registered Nurse Clinical Coordinator
WVU Medicine | Morgantown, WV
10.2017 - 07.2019
- Perform Medicare annual Wellness Visits in collaboration with a physician
- Manage and monitor anticoagulation therapy
- Assess patient needs post discharge to ensure a smooth transition between hospital and home setting
- Focus on preventions of illness and progression of co-morbid conditions through creating a prevention plan with patients
- Collaborate closely with case management to perform outreach and assist in management of patients with chronic conditions
- Access quality reports and collaborate with physicians to meet benchmarks for data reporting
- Provide education in multi-disciplinary clinics
Licensed Practical Nurse
Mon General Hospital | Morgantown, WV
06.2014 - 09.2017
- Patient assessments including geriatric population
- Phone triage and appointment scheduling
- Provide clinical care encompassing both acute and chronic medical conditions
- Initiate referrals for patients as indicated by physicians
- Report on PQRS quality measures by submitting accurate patient data required by Medicare
- Communicate with patient's insurance companies for prior authorization purposes
- Conduct point of care testing and monthly controls to adhere to hospital policy
Education
Associates Degree - Science And Nursing
Fairmont State University
Fairmont, WV01.2017
Licensed Practical Nurse - undefined
Fred Eberle School of Practical Nursing
Buckhannon, WV01.2011
Registered Medical Assistant - undefined
MTECH
Morgantown, WV01.2009
Skills
- Proficient with MCG
- Basic IGCM certification
- Discharge Planning
- Transition of care
- Care plan development
- Preventative health maintenance
- Healthcare billing codes
- Patient referral process
- Microsoft Office
- Diabetes and nutrition education
- Medicare and Medicaid eligibility
- Patient and family advocacy
- ICD10
- Clinical documentation
- Clinical judgment
- Compact State Licensure
Timeline
Nurse Medical Management
Wellpoint | Elevance Health
03.2021 - Current
Registered Nurse Case Manager
Elevance Health
07.2019 - 03.2021
Registered Nurse Clinical Coordinator
WVU Medicine | Morgantown, WV
10.2017 - 07.2019
Licensed Practical Nurse
Mon General Hospital | Morgantown, WV
06.2014 - 09.2017
Licensed Practical Nurse - undefined
Fred Eberle School of Practical Nursing
Registered Medical Assistant - undefined
MTECH
Associates Degree - Science And Nursing
Fairmont State University
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