Ayesha Walker
Boca Raton,FL
Summary
Seasoned Care Coordinator & Utilization Review Nurse with a proven track record of success. Expert in medical records review and motivational interviewing which leads to enhancing patient wellness. Skilled in team collaboration and conflict resolution, consistently achieving optimal patient outcomes through effective care plans and treatment strategies. Patient-focused equipped with administrative and customer service expertise. Helps keep healthcare services proceeding smoothly by coordinating communications, referrals, and policy enforcement. Talented in finding balanced solutions and resolving conflicts.
Overview
13
13
years of professional experience
1
1
Certification
Work History
Care Coordinator & Utilization Review Nurse
Aware Recovery Care
Delray Beach, FL
01.2023 - Current
- Identifies, assesses and evaluates the patients’ needs and requirements to achieve and maintain optimal wellness and sobriety in the least restrictive setting
- Coordinates and implements new and existing treatment and care plans based on the patient's specific recovery needs
- Guides, direct and assists members and their families with outside resources and referrals appropriate for the patients care
- Identifies, plans and implements interventions such as support groups and motivational interviewing to aid in the patient's overall care
- Review of medical records speaking with payors and providers to establish continuation of care
- Evaluation of the patient's progress on a consistent basis which includes crisis intervention when appropriate
- Provides education and support to patients that help them identify their path to recovery and optimal mental health
- Initiates insurance verification, prior authorization, concurrent reviews and medical necessity for continued care
Case Management Nurse
Epilepsy Alliance Florida
Deerfield Beach, FL
01.2020 - 01.2024
- Provide consumers with education and facilitate enrollment into a Qualified Health Plan available through the Federal Marketplace
- Conduct outreach and education through health fairs, presentations, events, and other potential opportunities to help consumers learn about the Health Insurance Marketplace, its relation to them, and the enrollment process
- Inform consumers of their rights to appeal eligibility, enrollment decisions, grievance process and assist with filing such
- Identify and establish collaboration with community-based organizations (CBO) and community sites for enrollment assistance, outreach and education events, and Health Literacy Workshops
- Guides, directs and assists consumers and their families with resources appropriate for the members’ care
- Abide by all agencies, federal and state policies, procedures, and mandates, including timely project reports, documentation and required data entry
- Provide education on the appropriate Qualified Health Plan pertaining to the medical necessity of each consumer
- Assists the consumer with selecting a healthcare provider, the initial appointment and with the coordination of care
- Provide wrap-around services, education and direct assistance to consumers in the ADAP-Ryan White programs
Clinical Care Coordinator & Utilization Review Nurse
Humana
Boca Raton, FL
01.2022 - 01.2023
- Identifies, assesses and evaluates the members’ needs and requirements to achieve and maintain optimal wellness in the least restrictive setting
- Coordinates and implements new and existing care plans based on the members’ specific needs
- Review of medical records speaking with payors and providers to establish the continuation of care
- Guides, directs and assists members and their families with resources appropriate for the members’ care
- Identifies, plans and conducts assessments to determine the needs of the members
- Collaborates with other pay sources, providers and interdisciplinary teams involved in the members care as required
- Abide by all agencies, federal and state policies, procedures, and mandates regarding timely documentation, reporting and evaluation of the member’s care
- Initiates insurance verification, prior authorization, concurrent reviews and medical necessity for continued care
Quality Assurance Nurse
Broward House Facility
Ft. Lauderdale, FL
01.2019 - 01.2020
- Continually evaluate and improve processes at all levels using data analysis
- Develop and implement processes for streamline data, evaluation and reporting
- Development and compilation of Performance Improvement reporting
- Monitors the development and implementation of the operational quality improvement program in various departments
- Completion of all evaluations and audits by Joint Commission standards and other regulatory agencies
- Develop and maintain up-to-date databases to track program outcomes
- Conduct chart, Medication Administration Record and nursing department audits as needed to monitor the quality of care being given
- Promote infection prevention, prevent adverse events, review clinical competency and ensure regulatory adherence
- Participate in training and working with leadership while troubleshooting problems and questions with staff, physicians and the leadership team
- Acting as a liaison with payers, providers and patients by promoting quality care and cost-effective outcomes for the facility
- Review and analyze complaints of patients and family members and come to a resolution
- Conduct in-service training to ensure nursing the department is up to date with all laws, regulatory standards and licensing requirements
Utilization Review Nurse
Detox of Delray
Delray Beach, FL
01.2016 - 01.2019
- Review medical records, treatment plans and ensure the best continuation of care for the patient
- Evaluate pre-authorizations for treatment and services and conduct concurrent reviews regarding medical necessity
- Coordinate health services with payors and providers regarding the patients care
- Assist with patient reimbursement, review payment denials and make recommendations
- Report patient conditions to insurance companies and provide periodic updates on patient conditions
- Respond to emails and calls from insurance companies and providers
- Identify discrepancies with payers regarding coverage benefits for patients in the program
- Review and analyze complaints of patients and family members and come to a resolution
- Evaluation of COWS and CIWA assessment scales for opioid and alcohol withdrawal
Medical Collections & Utilization Review Nurse
Wimbledon Health Partners
Boca Raton, FL
01.2015 - 01.2017
- Process denied and rejected claims from payers and conducted research as to why claims have been rejected and/or denied
- Initiated calls to payers to follow up on claim status for payment, escalation and concurrent reviews
- Observe, identify and analyze coding & modifier errors and denial patterns
- Monitor and respond on a consistent basis to client accounts that have failed payments, past due balances and large balances to ensure accounts receivable are current
- Review medical records and medical necessity information regarding claims
- Proactively communicate with insurance carriers through payer portals and process documentation on the portal site regarding authorizations
- Educate clients on explanation of benefits, client’s responsibility and the payer paid portion of the claim
- Process, submit and research medical records of clients to ensure accuracy of claim
- Process and initiate outbound calls to payers and clients and handle inbound calls
- Create, process and submit payer denials and appeals of medical claims
- Create, accept and process payment plans and accept different methods of payment such as credit cards, checks, 3rd party payments, out of network checks and automatic autopay
- Perform all collection duties within the HIPAA regulations and guidelines following federal and regulatory laws
- Process client disputes and inquiries regarding medical claims and invoices
Nurse Supervisor
Access Recovery Solutions
Delray Beach, FL
01.2014 - 01.2015
- Supervise the administration of nursing services by developing and deploying a simpler system to measure and manually calculate the narcotics count
- Maintain nursing guidelines by working with the Program Director to update policies and procedures
- Complete patient care requirements by monitoring and assessing the duties of other staff such as License Practical Nurses
- Develop staff by orienting, training and coaching the nursing staff as well as communicating the job expectations
- Provide information to patients, family and the health care team regarding the quality of care
- Conduct chart, Medication Administration Record and nursing department audits as needed to monitor the intake and outgoing of narcotics and patient care
- Create, process and submit narcotic orders to the participating pharmacy
- Assist in the admission and discharge process of the patient from the program
- Conduct group sessions with patients on infection control, medication administration and management with Methadone
- Conduct an as needed basis audit of the nursing station to make sure equipment, documentation and medications are within regulatory standards
LICENSED PRACTICAL NURSE
Palm Partners Recovery
Delray Beach, FL
01.2012 - 01.2014
- Identify and prioritize client care needs utilizing the nursing assessment and client history
- Perform daily client medication administration, vital signs, treatments and client education
- Conduct assessments using the COWS, CIWA & PAWS assessment scale
- Initiate admissions and discharges for clients entering and departing from the program
- Monitor clients on taper protocols and communicate with the provider with any change in the client’s status
- Complete daily charting on clients and transcribe any new or updated doctors’ orders
- Observe and assess patients for clinical signs and symptoms and monitor the clients during the detoxification process
- Perform clinical nursing activities in a safe professional manner and maintain compliance within nursing care standards
Education
MBA - Healthcare Administration
South University
West Palm Beach, FL01.2020
Bachelor of Science - Legal Studies (Focus in Healthcare Law)
South University
West Palm Beach, FL01.2017
Associate degree - Licensed Practical Nurse
Academy of Nursing & Health Occupations
West Palm Beach, FL01.2011
Skills
- Claims processing
- Documentation
- Resource allocation
- Team collaboration
- Discharge planning
- Patient assessment
- Care plan and treatment plan
- Time management
- Medical records review
- Motivational interviewing
- Insurance verification
- Health literacy
- Medical terminology understanding
- Conflict resolution
Certification
- Nurse Management
- HIPAA (Health Insurance Portability and Accountability Act)
- ACLS
- Medication Error
- ACA Certified
- 701B Elders Affair
- Nurse Educator & Training
- Licensed Insurance Navigator through CMS
Systems
- Availity
- CMD
- ARS400
- KIPU
- Oracle NetSuite
- Medisoft
- Microsoft Office
- Excel
- Monday.com
- Zen Charts
- E-Clinical Works
- Survey Monkey
- Aura
- Drop Box
- Adobe Pro
Timeline
Care Coordinator & Utilization Review Nurse
Aware Recovery Care
01.2023 - Current
Clinical Care Coordinator & Utilization Review Nurse
Humana
01.2022 - 01.2023
Case Management Nurse
Epilepsy Alliance Florida
01.2020 - 01.2024
Quality Assurance Nurse
Broward House Facility
01.2019 - 01.2020
Utilization Review Nurse
Detox of Delray
01.2016 - 01.2019
Medical Collections & Utilization Review Nurse
Wimbledon Health Partners
01.2015 - 01.2017
Nurse Supervisor
Access Recovery Solutions
01.2014 - 01.2015
LICENSED PRACTICAL NURSE
Palm Partners Recovery
01.2012 - 01.2014
MBA - Healthcare Administration
South University
Bachelor of Science - Legal Studies (Focus in Healthcare Law)
South University
Associate degree - Licensed Practical Nurse
Academy of Nursing & Health Occupations
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