Summary
Overview
Work History
Education
Skills
Websites
Accomplishments
Certification
Linkedin2
Email2
Awards
Spending quality time with my family, knitting, and scuba diving.
Languages
Timeline
Generic

Beverlyn Robert

Vernon Hills,IL

Summary

Empathetic & Patient-focused ADON & Nurse Case Manager offering 25 years of experience working with patients and families to facilitate smooth transitions following discharge from medical facilities. Committed to working collaboratively with health plan, leadership and department coordinators to achieve highest quality of patient satisfaction. Well-versed in developing individualized care plans and advocating patient welfare.

Overview

17
17
years of professional experience
1
1
Certification

Work History

ADON & Telehealth Chronic Nurse Case Manager

Precise Telehealth, Inc.
09.2018 - 12.2023
  • Responsible for performing all aspects of remote nurse case management services with physician partners; helping patients manage multiple chronic conditions such as, DMII, HTN, CKD, cancer, COPD, arthritis, and other health chronic conditions
  • Worked close with the CCM clinical team in Illinois, Indiana, Texas, and California to develop, implement, and evaluate individualized patient care plans
  • Responsible for educating, instructing, coaching, and mentoring patients, and advocating patient welfare
  • Served as a liaison between patients, their families, and the healthcare providers
  • Phoned and would video conference with my patients’ daily and with the telehealth CCM team twice a week
  • Consulted with the company’s CEO-founder and Vice President regarding the CCM program goals, implementation, and solutions
  • Knowledgeable with the company’s cloud-based patient case management platform and patient engagement tools
  • Fluent in navigating the Elation case management software
  • Assessed barriers to patient self-care and health management remotely
  • Created company ideas and solutions and gathered resources to assist the company barriers in an ongoing process of assessment, provider communication, education, well coach referral and encouragement
  • Worked closely with the medical directors, the patients, the patients’ primary caregivers and their referring physicians to achieve healthier outcomes for the patients at risk in clinical deterioration due to multiple comorbidities
  • Integrated and utilized quality assurance measures, legal and ethical issues in case management, utilization management, utilization review, designing case management models with the Blood Pressure Remote Patient Monitoring (BPRPM) program, and the wellness coach program
  • Created, implemented, and managed the company’s Blood Pressure Remote Patient Monitoring (BPRPM) Telehealth Technology Program three years pre-pandemic to embrace, care and advocate for the patient’s healthcare
  • Met face to face with the company physicians to discuss and manage the company’s CPT commercial insurance and managed care organization reimbursement process and policies in the state of Illinois and Indiana
  • Fluent in English and in Spanish speaking, reading, and writing
  • Licensed practical nurse (LPN) practicing in four different states, CA, IN, TX, and IL
  • Supervisory and director of nursing experience.
  • Reported findings to quality departments after conducting routine restraint audits and worked with team to devise corrective actions for deficiencies.
  • Delivered high level of quality care to diverse populations while overseeing patient admission and triaging based on acuity and appropriate department admission.
  • Ensured regulatory compliance by staying current on industry best practices and maintaining meticulous documentation records.
  • Conveyed treatment options, diagnosis information and home care techniques to patients and caregivers to continue care consistency.
  • Managed support services and fostered communication among social workers, therapists, hospital staff, and patients.
  • Facilitated smooth transitions between healthcare settings by effectively communicating pertinent information to receiving facilities or home health agencies.
  • Enhanced interdisciplinary team communication, ensuring timely and accurate updates on patient progress.
  • Conducted thorough assessments to identify gaps in care and develop targeted interventions for improvement.
  • Led teams in driving successful patient outcomes by prioritizing standard of care and best practices.
  • Educated patients on disease management techniques, empowering them to take control of their health and reduce complications.
  • Optimized resource utilization by identifying opportunities for cost containment without compromising care quality.
  • Collaborated with leadership to devise initiatives for improving nursing satisfaction, retention and morale.
  • Participated in evidence-based practice project implementation, nursing competency development and nursing simulation activities.
  • Gathered and recorded patient health information and data to assess, identify and manage characteristics that affect care outcome.
  • Educated patients and caregivers on healthcare protocols and processes.
  • Conducted preoperative risk assessments, ongoing assessments and evaluations to prepare patients for surgery and manage healing process.
  • Implemented aspects of patient care under physician orders and sought clarification when needed to promote safety, quality and cost-efficient care.
  • Served as a liaison between patients and various support services such as financial assistance programs, community resources, and mental health counseling to ensure holistic care was provided.
  • Sustained quality standards by performing routine medication audits and upholding internal and industry best practices.
  • Promoted patient and family comfort during challenging recoveries to enhance healing and eliminate non-compliance problems.
  • Utilized professional network to increase referrals from contracted providers to the referral and admission-intake department.
  • Developed strong relationships with patients, families, and healthcare providers, fostering trust and open communication resulting in improved satisfaction scores.
  • Initiated cross-discipline collaboration efforts that led to improved patient outcomes across various departments in the facility.
  • Offered exceptional care and support to individuals recovering from acute incidents and dealing with chronic conditions.
  • Evaluated patient histories, complaints, and current symptoms.
  • Developed the (Blood Pressure Remote Patient Monitoring) BPRPM referral program to maintain long-term patient wellness.
  • Collaborated with multidisciplinary teams to devise evidence-based treatment plans that improved patient satisfaction scores.
  • Communicated with healthcare team members to plan, implement and enhance treatment strategies.
  • Performed telemetry monitoring of patients cardiac rhythms and properly recorded data.
  • Advocated for patient needs, addressing concerns with healthcare providers and insurance companies to ensure optimal care was received.
  • Observed and documented patient factors such as diets, physical activity levels, and behaviors to understand conditions and effectively modify treatment plans.
  • Evaluated clinical data trends over time, identifying areas requiring process improvements that ultimately led to better overall patient experiences.
  • Initiated and created (Blood Pressure Remote Patient Monitoring) BPRPM patient program successfully boosting profits.
  • Assisted with the implementation of new technology solutions that streamlined communication and improved the overall efficiency of care coordination.
  • Managed caseloads efficiently, prioritizing high-risk cases while ensuring all patients received appropriate attention and support.
  • Quickly responded to situations impacting safety and security to unit, actualizing crisis prevention interventions to control and de-escalate situations.
  • Streamlined documentation processes, saving time for both staff and patients while maintaining accuracy.
  • Reduced hospital readmissions through vigilant monitoring and prompt intervention for at-risk patients.
  • Leveraged feedback and process improvement opportunities to create safer and healthier environment and increase patient satisfaction.
  • Analyzed patient responses to medications, therapies and variances in plans of care.
  • Fostered partnerships to increase patient influx and facilitate hospital development.
  • Explained course of care and medication side effects to patients and caregivers in easy-to-understand terms.
  • Implemented care plans for patient treatment after assessing physician medical regimens.
  • Used first-hand knowledge and clinical expertise to advocate for patients under care and enacted prescribed treatment strategies.
  • Conducted ongoing monitoring and evaluations of behaviors and conditions, and updated clinical supervisors with current information.
  • Increased referral rates by providing excellent service and building meaningful relationships with patients and caregivers.
  • Educated family members and caregivers on patient care instructions.
  • Followed all personal and health data procedures to effectively comply with HIPAA laws and prevent information breaches.
  • Performed frequent checks on life support equipment and made necessary adjustments to preserve optimal patient conditions.
  • Applied critical thinking skills during case reviews to identify potential risks or challenges before they escalated into larger issues.
  • Promoted continuity of care by coordinating with healthcare providers, social workers, and family members in the development of discharge plans.
  • Equipped patients with tools and knowledge needed for speedy and sustained recovery.
  • Drove patient influx 70% through effective marketing techniques and maintaining excellent satisfaction rates.
  • Facilitated therapeutic communication, conflict resolution and crisis intervention by redirecting negative behaviors and helping patients regain or improve coping abilities.
  • Collaborated with healthcare leaders and physicians to support and offer resources in performance of duties to maintain high-quality and efficient patient care.
  • Managed patients recovering from medical or surgical procedures.
  • Provided exceptional care to high-acute patients needing complex care such as ventilator management, extensive wound care and rehabilitation.
  • Mentored new hires, sharing knowledge and expertise to foster a supportive learning environment promoting professional growth within the nursing team.
  • Provided skilled, timely and level-headed emergency response to critically-ill patients.
  • Improved patient outcomes by developing and implementing comprehensive care plans tailored to individual needs.
  • Developed and modified patient care plans and assisted interdisciplinary team in identifying client needs and goals to determine priorities of care.
  • Resolved problems, improved operations and provided exceptional service.
  • Participated in team projects, demonstrating an ability to work collaboratively and effectively.
  • Gained strong leadership skills by managing projects from start to finish.
  • Used strong analytical and problem-solving skills to develop effective solutions for challenging situations.
  • Self-motivated, with a strong sense of personal responsibility.
  • Proven ability to learn quickly and adapt to new situations.
  • Developed and maintained courteous and effective working relationships.
  • Assisted with day-to-day operations, working efficiently and productively with all team members.
  • Strengthened communication skills through regular interactions with others.
  • Demonstrated leadership skills in managing projects from concept to completion.
  • Learned and adapted quickly to new technology and software applications.
  • Provided professional services and support in a dynamic work environment.
  • Paid attention to detail while completing assignments.
  • Completed paperwork, recognizing discrepancies and promptly addressing for resolution.
  • Demonstrated a high level of initiative and creativity while tackling difficult tasks.
  • Applied effective time management techniques to meet tight deadlines.
  • Delivered services to customer locations within specific timeframes.
  • Reduced medication errors by conducting thorough medication administration audits and providing feedback to nursing staff.

Utilization Management Specialist and Transition of Care Coordinator

Family Health Network
02.2011 - 07.2016
  • Responsible for performing all aspects of UM and TCC for Nonprofit Managed Care Organization in IL
  • Responsible for evaluating the appropriateness, medical necessity encountered and the efficiency of health care services, procedures, and facilities according to established criteria, Interqual & the health plans criteria/guidelines
  • Worked very close with the ten medical groups and serviced about 25,000 members to ensure timely implementation of discharge need, discharge plans and referred members to case management as needed
  • Assisted the members in the TANF-ACA population with access to services, such as SW, understanding of medical necessities and assisted the members with health incentives
  • Supported the ten medical groups and CM staff with problem solving of medical care related issues with providers
  • Participated in UM, TCC and department board meetings as required
  • Included UM decisions based upon the analysis of a case, based on prospective, retrospective, and concurrent reviews that intend to manage health care cases efficiently and cost effectively
  • Promoted healthcare quality to our accrediting healthcare organization and ten medical groups
  • Performed proactive review procedures such as pre-certification, referrals, and concurrent clinical review, discharge planning and clinical case appeals
  • Presented high risk cases to our health plan Medical Director in the board room in a group setting once a week
  • Complete on-line UM and UR webinar courses for FHN- UM department
  • Worked assisting the HEDIS department with locating A1c levels, current BP results, current immunizations, breast X-ray results, and current blood testing results
  • Performed admission reviews based for medical necessity based upon Milliman Guideline specifications.
  • Participated in interdisciplinary rounds meetings regularly, advocating for patient needs while considering cost-effectiveness factors.
  • Established strong relationships with external stakeholders, fostering collaboration around shared goals of quality improvement and cost containment.
  • Managed patients recovering from medical or surgical procedures.
  • Communicated with healthcare team members to plan, implement and enhance treatment strategies.
  • Implemented care plans for patient treatment after assessing physician medical regimens.
  • Educated family members and caregivers on patient care instructions.
  • Offered exceptional care and support to individuals recovering from acute incidents and dealing with chronic conditions.
  • Enhanced patient care by monitoring utilization trends and identifying areas for improvement.
  • Streamlined workflow by implementing efficient case management processes for optimal results.
  • Ensured compliance with industry standards and regulations, conducting regular audits and implementing corrective actions when necessary.
  • Delivered high level of quality care to diverse populations while overseeing patient admission and triaging based on acuity and appropriate department admission.
  • Explained course of care and medication side effects to patients and caregivers in easy-to-understand terms.
  • Contributed to the development of evidence-based clinical protocols, promoting consistent decision-making across the organization.
  • Collaborated with leadership to devise initiatives for improving nursing satisfaction, retention and morale.
  • Conducted ongoing monitoring and evaluations of behaviors and conditions, and updated clinical supervisors with current information.
  • Conducted in-depth assessments to determine the appropriateness of medical services, resulting in cost-effective care delivery.
  • Facilitated communication between providers and payers, resolving authorization issues promptly.
  • Provided ongoing support to nursing staff through education on utilization management concepts as well as mentoring new team members.
  • Reduced unnecessary healthcare costs, analyzing and optimizing resource allocation.
  • Coordinated discharge planning efforts, ensuring seamless transitions from acute care settings to post-acute environments or home-based services.
  • Conveyed treatment options, diagnosis information and home care techniques to patients and caregivers to continue care consistency.
  • Evaluated patient histories, complaints, and current symptoms.
  • Observed and documented patient factors such as diets, physical activity levels, and behaviors to understand conditions and effectively modify treatment plans.
  • Played a critical role in accreditation processes by maintaining up-to-date knowledge of regulatory requirements and ensuring adherence to standards.
  • Led teams in driving successful patient outcomes by prioritizing standard of care and best practices.
  • Used first-hand knowledge and clinical expertise to advocate for patients under care and enacted prescribed treatment strategies.
  • Quickly responded to situations impacting safety and security to unit, actualizing crisis prevention interventions to control and de-escalate situations.
  • Facilitated workgroup meetings with medical personnel to find effective solutions to issues.
  • Supervised and maintained all utilization review documentation through internal case management software.
  • Managed a diverse caseload of patients, coordinating care across multiple service lines for optimal outcomes.
  • Devise or identify solutions for irregular requests and issues.
  • Investigated and resolved issues affecting hospital operations and patient care.
  • Submitted cases for criteria failures and helped facilitate resolutions and approvals.
  • Participated in evidence-based practice project implementation, nursing competency development and nursing simulation activities.
  • Facilitated therapeutic communication, conflict resolution and crisis intervention by redirecting negative behaviors and helping patients regain or improve coping abilities.
  • Leveraged feedback and process improvement opportunities to create safer and healthier environment and increase patient satisfaction.
  • Evaluated medical guidelines and benefit coverage to determine appropriateness of services.
  • Followed all personal and health data procedures to effectively comply with HIPAA laws and prevent information breaches.
  • Evaluated emerging trends in healthcare delivery, making strategic recommendations to enhance organizational performance.
  • Equipped patients with tools and knowledge needed for speedy and sustained recovery.
  • Reviewed medical records meticulously to verify appropriate level-of-care determinations, reducing potential overpayments or denials.
  • Performed prior authorization review of services requiring notification.
  • Promoted a culture of continuous improvement by actively participating in quality assurance initiatives and sharing best practices with colleagues.
  • Improved overall efficiency with thorough utilization reviews and data-driven recommendations.
  • Provided skilled, timely and level-headed emergency response to critically-ill patients.
  • Provided exceptional care to high-acute patients needing complex care such as ventilator management, extensive wound care and rehabilitation.
  • Obtained authorizations from multiple insurance carriers for various levels of care.
  • Recorded details regarding therapies to keep patient charts updated.
  • Reported findings to quality departments after conducting routine restraint audits and worked with team to devise corrective actions for deficiencies.
  • Worked well in a team setting, providing support and guidance.
  • Demonstrated a high level of initiative and creativity while tackling difficult tasks.
  • Managed time efficiently in order to complete all tasks within deadlines.
  • Skilled at working independently and collaboratively in a team environment.
  • Adaptable and proficient in learning new concepts quickly and efficiently.
  • Excellent communication skills, both verbal and written.
  • Self-motivated, with a strong sense of personal responsibility.
  • Participated in team projects, demonstrating an ability to work collaboratively and effectively.
  • Demonstrated strong organizational and time management skills while managing multiple projects.
  • Worked effectively in fast-paced environments.
  • Strengthened communication skills through regular interactions with others.
  • Resolved problems, improved operations and provided exceptional service.
  • Gained extensive knowledge in data entry, analysis and reporting.
  • Learned and adapted quickly to new technology and software applications.
  • Demonstrated creativity and resourcefulness through the development of innovative solutions.
  • Developed strong organizational and communication skills through coursework and volunteer activities.
  • Organized and detail-oriented with a strong work ethic.
  • Completed paperwork, recognizing discrepancies and promptly addressing for resolution.
  • Assisted with day-to-day operations, working efficiently and productively with all team members.
  • Created customized care plans, working with hospital staff and families to assess and meet individual needs.
  • Streamlined information sharing between healthcare providers by implementing secure electronic communication systems.
  • Conducted regular evaluations of care plan effectiveness, making necessary adjustments based on feedback from patients and providers.
  • Determined need for special assessment activities for complex cases, effectively handling care plans.
  • Implemented evidence-based interventions that improved overall patient satisfaction with the care process.
  • Successfully negotiated client contract renewals to create increased revenue.
  • Monitored, tracked, and conveyed important patient information to healthcare staff to help optimize treatment planning and care delivery.
  • Managed patient caseloads effectively, ensuring timely follow-up and appropriate interventions.
  • Liaised with other healthcare professionals to develop comprehensive patient care plans and provide highest quality of care.
  • Developed and updated policies and procedures, maintaining compliance with guidelines relating to HIPAA, benefits administration and general liability.
  • Communicated with patients, ensuring that medical information was kept private.
  • Designed and introduced leadership development, coaching and team management model, resulting in promotion of employees into increased levels of responsibility.
  • Ordered all pharmacy supplies and kept check on inventory levels.
  • Facilitated appointments and transportation for patients, streamlining access to essential medical services.
  • Contributed to the development of organizational policies and procedures related to care coordination, ensuring alignment with industry standards and best practices.
  • Advocated for patients'' rights within the healthcare system, working diligently to address concerns or barriers to care.
  • Completed resident assessments in accordance with current regulations and guidelines.
  • Implemented successful healthcare program through professionalism, quality of care, medical teaching and patient satisfaction.
  • Supported patient care excellence via planning and interpretation of programs.
  • Provided emotional support for patients and families during difficult times, fostering resilience and coping skills.
  • Established and maintained effective communication with staff, physicians and community organizations to promote high quality patient care.
  • Used company software and databases to maintain records of services performed and patient conditions.
  • Monitored progress towards patient goals, adjusting care plans as needed to achieve desired results.
  • Discussed medical histories with patients in effort to provide most effective medical advice.
  • Developed strong relationships with community partners, facilitating referrals and collaboration on behalf of patients.
  • Assisted in managing medication regimens for complex cases, reducing potential errors or adverse effects on patients'' health.
  • Built strong relationships with clients to deliver emotional support and companionship.
  • Recruited, hired and trained all staff, providing direct supervision, ongoing staff development and continuing education to employees.
  • Utilized data analysis tools to identify trends in patient needs, allowing for more targeted intervention strategies.
  • Assessed patient needs and connected them with appropriate resources to ensure optimal health outcomes.
  • Educated patients on self-care strategies, promoting independence and empowering them to manage their health conditions.
  • Coordinated discharge planning, ensuring a smooth transition from hospital to home or other facilities.
  • Identified issues, analyzed information and provided solutions to problems.
  • Provided professional services and support in a dynamic work environment.

Utilization Management Specialist

NextLevel Health Partners
08.2016 - 08.2018
  • Responsible for reviewing precertification requests and medical necessity for Outpatient, Inpatient and Behavioral Health cases in the FHP, ACA adult and SPD populations
  • Utilization Management Specialist for a Medicaid, Nonprofit Managed Care Organization in the state of Illinois
  • Managed a caseload of seventy-five to one hundred high risk members per week
  • Responsible for assuring the receipt of high quality, cost efficient medical outcomes for NLHP enrollees identified as having the need for inpatient and or outpatient precertification or preauthorization according to established criteria, Interqual & the health plans internal criteria/ guidelines
  • Established strong relationships with external stakeholders, fostering collaboration around shared goals of quality improvement and cost containment.
  • Communicated with healthcare team members to plan, implement and enhance treatment strategies.
  • Quickly responded to situations impacting safety and security to unit, actualizing crisis prevention interventions to control and de-escalate situations.
  • Ensured compliance with industry standards and regulations, conducting regular audits and implementing corrective actions when necessary.
  • Promoted a culture of continuous improvement by actively participating in quality assurance initiatives and sharing best practices with colleagues.
  • Facilitated workgroup meetings with medical personnel to find effective solutions to issues.
  • Conveyed treatment options, diagnosis information and home care techniques to patients and caregivers to continue care consistency.
  • Supervised and maintained all utilization review documentation through Interqual and ODG case management software.
  • Supervised and maintained all utilization review documentation through the internal case management software.
  • Improved overall efficiency with thorough utilization reviews and data-driven recommendations.
  • Delivered high level of quality care to diverse populations while overseeing patient admission and triaging based on acuity and appropriate department admission.
  • Participated in evidence-based practice project implementation, nursing competency development and nursing simulation activities.
  • Conducted ongoing monitoring and evaluations of behaviors and conditions, and updated clinical supervisors with current information.
  • Performed admission reviews based for medical necessity based upon Inpatient admission specification.
  • Performed prior authorization review of services requiring notification.
  • Facilitated communication between providers and payers, resolving authorization issues promptly.
  • Managed patients recovering from medical or surgical procedures.
  • Collaborated with leadership to devise initiatives for improving nursing satisfaction, retention and morale.
  • Devise or identify solutions for irregular requests and issues.
  • Assisted with the implementation of new software systems designed specifically for utilization management purposes, improving data tracking and reporting capabilities.
  • Streamlined workflow by implementing efficient case management processes for optimal results.
  • Coordinated discharge planning efforts, ensuring seamless transitions from acute care settings to post-acute environments or home-based services.
  • Managed a diverse caseload of patients, coordinating care across multiple service lines for optimal outcomes.
  • Reduced unnecessary healthcare costs, analyzing and optimizing resource allocation.
  • Used first-hand knowledge and clinical expertise to advocate for patients under care and enacted prescribed treatment strategies.
  • Evaluated medical guidelines and benefit coverage to determine appropriateness of services.
  • Conducted in-depth assessments to determine the appropriateness of medical services, resulting in cost-effective care delivery.
  • Followed all personal and health data procedures to effectively comply with HIPAA laws and prevent information breaches.
  • Implemented care plans for patient treatment after assessing physician medical regimens.
  • Reported findings to quality departments after conducting routine restraint audits and worked with team to devise corrective actions for deficiencies.
  • Provided ongoing support to nursing staff through education on utilization management concepts as well as mentoring new team members.
  • Leveraged feedback and process improvement opportunities to create safer and healthier environment and increase patient satisfaction.
  • Documented treatments delivered, medications and IVs administered, discharge instructions, and follow-up care.
  • Contributed to the development of evidence-based clinical protocols, promoting consistent decision-making across the organization.
  • Enhanced patient care by monitoring utilization trends and identifying areas for improvement.
  • Obtained authorizations from multiple insurance carriers for various levels of care.
  • Participated in interdisciplinary rounds meetings regularly, advocating for patient needs while considering cost-effectiveness factors.
  • Provided skilled, timely and level-headed emergency response to critically-ill patients.
  • Observed and documented patient factors such as diets, physical activity levels, and behaviors to understand conditions and effectively modify treatment plans.
  • Provided exceptional care to high-acute patients needing complex care such as ventilator management, extensive wound care and rehabilitation.
  • Reviewed medical records meticulously to verify appropriate level-of-care determinations, reducing potential overpayments or denials.
  • Played a critical role in accreditation processes by maintaining up-to-date knowledge of regulatory requirements and ensuring adherence to standards.
  • Resolved problems, improved operations and provided exceptional service.
  • Self-motivated, with a strong sense of personal responsibility.
  • Proven ability to learn quickly and adapt to new situations.
  • Used critical thinking to break down problems, evaluate solutions and make decisions.
  • Demonstrated strong organizational and time management skills while managing multiple projects.
  • Exercised leadership capabilities by successfully motivating and inspiring others.
  • Worked well in a team setting, providing support and guidance.
  • Participated in team projects, demonstrating an ability to work collaboratively and effectively.
  • Cultivated interpersonal skills by building positive relationships with others.
  • Paid attention to detail while completing assignments.
  • Skilled at working independently and collaboratively in a team environment.
  • Organized and detail-oriented with a strong work ethic.
  • I was also responsible for providing UM services across the member continuum of care to improve health outcomes of the members served, and reviewed medical cases referred to the Medical Director that required additional determination expertise
  • I reviewed clinical information for concurrent, and retrospective referrals, extending the length of stay for inpatients cases as appropriate
  • In addition, I was responsible for utilizing coordination of services, resource management, education, patient advocacy, related interventions to promote improved quality of care or life, promote cost effective medical outcomes, prevent hospitalizations when possible & appropriate, prevent complications in patients under NLH care when possible, provide continuity of care, and assured appropriate levels of care that were received by patients
  • I provided appropriate consultation and referrals to the Case Management personnel
  • I was responsible for providing advice and counsel to precertification staff, and I identified appropriate alternative and non-traditional resources and demonstrated creativity in managing each case to fully utilize all available resources
  • I supported company and departmental QA/QI initiatives, and relayed to my UM Director
  • I served as a liaison with behavioral health contractors for transition of care cases, I provided clinical interface with care coordination services to identify high risk members who required judicial and/ or social intervention and monitoring
  • I performed case assessments, clinical support, education, and QM of members care for IP psychiatric care
  • I was responsible for facilitating the delivery of appropriate types of UM services through acute care, ancillary services, institutional facilities, and community-based services
  • Moreover, I presented high risk cases to the NLHP plan Medical Director in the board room in group setting once a week
  • I completed & passed the AAMCN (American Association of Managed Care Nurses) post-test & received 19 CNE credits
  • My goal as a UM Specialist was to reduce fragmentation of care & services, increase members options of care, reduce the rate of institutionalization, improve access to care and services, and function as a member advocate
  • I worked hybrid and then fully remote prepandemic.

Worker’s Compensation Utilization Review Nurse & Nurse Case Manager

Triune Health Group, Inc.
02.2010 - 02.2011
  • Responsible for performing all aspects of utilization review & telephonic case management process with workers compensation cases, general liability claims and utilization of resources and cost-effectiveness
  • Responsible for reviewing medical records and requests for UR and case management
  • Utilized evidence (ODG) based guidelines to determine if authorization of medical necessity could be given
  • Wrote nurse summaries on all UR files, tracked time for invoicing, documented properly in the database, sent appropriate Certification, Non-Certification and Appeal letters on each completed UR case to the adjuster, claimant, treating MD and claimant’s attorney
  • Established collaborative relationships with clients/ adjusters, patients, employers, providers/ medical directors
  • Tracked on going statuses of all utilization review activity so that the appropriate turnaround times for the workman compensation cases were met
  • Maintained & organized files containing clinical documentation of interactions with all parties, provided professional nursing insight, consultation to the director of nursing, the medical director and adjuster’s
  • Adhered to quality standard workman compensation UR guidelines
  • Maintained in-depth knowledge of all company products and services as well as customer issues and trends in Workman Compensation, Utilization Review
  • Adhered to the company policies, procedures and reporting requirements; assisted with URAC accreditation and upkeep of policies/ procedures and performed other administrative or corporate duties upon request
  • Reported to my VP assigned to my department
  • Responsible for marketing utilization review and case management services to adjuster’s and other community referral resources
  • Created and supplied success stories for marketing purposes
  • Offered exceptional care and support to individuals recovering from acute incidents and dealing with chronic conditions.
  • Assisted discharge planning efforts through prompt identification of medically stable patients who were ready for transition to alternate levels of care.
  • Facilitated therapeutic communication, conflict resolution and crisis intervention by redirecting negative behaviors and helping patients regain or improve coping abilities.
  • Supervised and maintained all utilization review documentation through ODG software.
  • Evaluated medical guidelines and benefit coverage to determine appropriateness of services.
  • Mitigated potential legal issues related to improper admission or discharge decisions by consulting with physicians regarding complex cases that required further clarification.
  • Demonstrated commitment to ethical practice by upholding patient confidentiality and advocating for individual rights in all interactions with stakeholders.
  • Communicated with healthcare team members to plan, implement and enhance treatment strategies.
  • Reduced healthcare costs through efficient utilization of resources and identification of unnecessary treatments or procedures.
  • Documented treatments delivered, medications and IVs administered, discharge instructions, and follow-up care.
  • Fostered a culture of continuous learning by actively participating in departmental meetings, trainings, and continuing education opportunities related to utilization review.
  • Increased staff efficiency by providing ongoing education on proper documentation techniques necessary for accurate claims processing.
  • Collaborated with leadership to devise initiatives for improving nursing satisfaction, retention and morale.
  • Promoted positive outcomes with proactive assessment of patients'' needs and development of targeted interventions to address identified barriers to recovery.
  • Streamlined the case management process by effectively prioritizing high-risk cases for timely intervention and followup.
  • Recorded details regarding therapies to keep patient charts updated.
  • Equipped patients with tools and knowledge needed for speedy and sustained recovery.
  • Maintained professional competence by staying current on industry trends, best practices, and regulatory requirements specific to utilization review nursing.
  • Participated in evidence-based practice project implementation, nursing competency development and nursing simulation activities.
  • Ensured compliance with regulations and accreditation standards by maintaining accurate documentation of all utilization review activities.
  • Delivered high level of quality care to diverse populations while overseeing patient admission and triaging based on acuity and appropriate department admission.
  • Improved patient care quality by conducting thorough utilization reviews and making recommendations for optimal treatment plans.
  • Performed prior authorization review of services requiring notification.
  • Followed all personal and health data procedures to effectively comply with HIPAA laws and prevent information breaches.
  • Participated in performance improvement initiatives designed to enhance service delivery while maintaining fiscal responsibility.
  • Served as a vital liaison between patients, healthcare providers, and insurance companies, fostering effective communication and coordination among all parties involved in the care process.
  • Quickly responded to situations impacting safety and security to unit, actualizing crisis prevention interventions to control and de-escalate situations.
  • Conducted ongoing monitoring and evaluations of behaviors and conditions, and updated clinical supervisors with current information.
  • Implemented care plans for patient treatment after assessing physician medical regimens.
  • Managed patients recovering from medical or surgical procedures.
  • Conveyed treatment options, diagnosis information and home care techniques to patients and caregivers to continue care consistency.
  • Supported data-driven decision-making by regularly analyzing trends in resource utilization, identifying opportunities for improvement, and implementing best practices.
  • Supported organizational growth and development through effective collaboration with interdisciplinary teams focused on improving the quality, safety, and efficiency of healthcare delivery.
  • Evaluated patient histories, complaints, and current symptoms.
  • Leveraged feedback and process improvement opportunities to create safer and healthier environment and increase patient satisfaction.
  • Developed strong communication and organizational skills through working on group projects.
  • Gained strong leadership skills by managing projects from start to finish.
  • Gained extensive knowledge in data entry, analysis and reporting.
  • Completed paperwork, recognizing discrepancies and promptly addressing for resolution.
  • Demonstrated creativity and resourcefulness through the development of innovative solutions.
  • Proven ability to develop and implement creative solutions to complex problems.
  • Assisted with day-to-day operations, working efficiently and productively with all team members.
  • Acted as a team leader in group projects, delegating tasks and providing feedback.
  • Excellent communication skills, both verbal and written.
  • Worked effectively in fast-paced environments.
  • Used critical thinking to break down problems, evaluate solutions and make decisions.
  • Initiated cross-discipline collaboration efforts that led to improved patient outcomes across various departments in the facility.
  • Ensured regulatory compliance by staying current on industry best practices and maintaining meticulous documentation records.
  • Advocated for patient needs, addressing concerns with healthcare providers and insurance companies to ensure optimal care was received.

Worker’s Compensation Utilization Review Specialist

Rising Medical Solutions
09.2008 - 09.2009
  • Responsible for performing all aspects of utilization review process with workers compensation, auto and general liability claims, utilization of resources and cost-effectiveness
  • Responsible for reviewing records and requests for UR, which were received via e-mail, e-fax or phone, utilized evidence-based guidelines to determine if authorization can be given
  • Wrote nurse summaries on all UR cases, tracked time for invoicing, documented properly in the database, sent appropriate letters, approval, modified or denial on each completed UR case
  • Established collaborative relationships with clients, patients, employers, providers/ medical directors
  • Tracked on going status of all utilization review activity so that the appropriate turnaround times were met in the states of IL, CA and TX
  • Provided professional nursing insight to the lead nurse or medical director
  • Adhered to quality standards, state billing, UR guidelines and confidentiality of all information, policies, and procedures
  • Maintained in-depth knowledge of all company products and services as well as customer issues and trends in Utilization Review
  • Reported to the team leader assigned to my department
  • Interacted on a regular basis with other members of the MRU team, MBA bill auditors and medical providers
  • Facilitated workgroup meetings with medical personnel to find effective solutions to issues.
  • Improved interdepartmental communication by collaborating with medical professionals, case managers, and social workers to develop comprehensive care plans.
  • Assisted with audits to ensure compliance with federal regulations governing Medicare and Medicaid reimbursements, safeguarding against potential penalties or sanctions from government agencies.
  • Demonstrated strong analytical skills by interpreting complex medical records and synthesizing relevant information for utilization review purposes.
  • Supported the development of standardized policies and procedures for utilization review across multiple departments within the organization.
  • Provided skilled, timely and level-headed emergency response to critically-ill patients.
  • Participated in ongoing professional development opportunities to stay current with trends and best practices in utilization review, bringing new insights back to the organization.
  • Managed a high volume of cases efficiently by prioritizing tasks and maintaining strict deadlines for completion of reviews.
  • Identified trends in healthcare usage among patients, providing valuable insights to inform strategic planning efforts within the organization.
  • Managed patients recovering from medical or surgical procedures.
  • Collaborated with interdisciplinary teams to create effective discharge plans that promoted optimal patient outcomes while minimizing hospital readmissions.
  • Followed all personal and health data procedures to effectively comply with HIPAA laws and prevent information breaches.
  • Used first-hand knowledge and clinical expertise to advocate for patients under care and enacted prescribed treatment strategies.
  • Contributed to organizational success by participating in quality improvement initiatives related to utilization management processes.
  • Enhanced patient care by conducting thorough utilization reviews and ensuring adherence to treatment plans.
  • Maintained strict confidentiality of patient information, adhering to HIPAA regulations and organizational policies regarding privacy and data security.
  • Collaborated with leadership to devise initiatives for improving nursing satisfaction, retention and morale.
  • Maintained regulatory compliance by staying updated on industry standards and guidelines, implementing changes when necessary.
  • Communicated with healthcare team members to plan, implement and enhance treatment strategies.
  • Evaluated patient histories, complaints, and current symptoms.
  • Evaluated medical guidelines and benefit coverage to determine appropriateness of services.
  • Reported findings to quality departments after conducting routine restraint audits and worked with team to devise corrective actions for deficiencies.
  • Participated in evidence-based practice project implementation, nursing competency development and nursing simulation activities.
  • Quickly responded to situations impacting safety and security to unit, actualizing crisis prevention interventions to control and de-escalate situations.
  • Provided timely feedback to physicians regarding patient progress, facilitating adjustments to treatment plans as needed.
  • Delivered high level of quality care to diverse populations while overseeing patient admission and triaging based on acuity and appropriate department admission.
  • Evaluated new protocols or interventions for cost-effectiveness and clinical utility, supporting evidence-based decision-making within the organization.
  • Reduced healthcare costs for the organization by identifying areas of improvement in clinical documentation and resource allocation.
  • Organized and detail-oriented with a strong work ethic.
  • Proven ability to learn quickly and adapt to new situations.
  • Passionate about learning and committed to continual improvement.
  • Resolved problems, improved operations and provided exceptional service.
  • Paid attention to detail while completing assignments.
  • Gained strong leadership skills by managing projects from start to finish.
  • Gained extensive knowledge in data entry, analysis and reporting.
  • Proved successful working within tight deadlines and a fast-paced environment.
  • Strengthened communication skills through regular interactions with others.
  • Adaptable and proficient in learning new concepts quickly and efficiently.
  • Identified issues, analyzed information and provided solutions to problems.
  • Provided professional services and support in a dynamic work environment.
  • Cultivated interpersonal skills by building positive relationships with others.
  • Used critical thinking to break down problems, evaluate solutions and make decisions.
  • Exercised leadership capabilities by successfully motivating and inspiring others.
  • Skilled at working independently and collaboratively in a team environment.

Utilization Review Nurse

WellPoint/ WellCare Health Insurance Services
09.2006 - 09.2008
  • Performed Utilization Review for members with complex and chronic care needs by assessing, implementing, developing, coordinating, monitoring and evaluating patients UR cases and care plans designed to optimize member health care across the care continuum and ensuring member access to services appropriate to their health needs
  • Primary duties included assessments to identify individual needs and a specific care management plan to address objectives and goals as identified during assessment
  • Implemented authorizations/ referrals as appropriate within benefits structure or through extra contractual arrangements
  • Coordinated internal and external resources to meet identified needs with providers
  • Monitored and evaluated effectiveness of the UR plan and modified as necessary per Milliman guidelines
  • Interfaced with the Medical Director and Physician advisors on the development of UR management/ treatment plans
  • Negotiated rates of reimbursement, as applicable
  • Assisted in problem solving with claims, service issues and providers
  • Worked at the corporate office inside the Sears Tower.
  • Conveyed treatment options, diagnosis information and home care techniques to patients and caregivers to continue care consistency.
  • Minimized financial risk associated with denials or payment discrepancies through diligent validation of medical necessity prior to service provision.
  • Recorded details regarding therapies to keep patient charts updated.
  • Fostered a culture of continuous learning by actively participating in departmental meetings, trainings, and continuing education opportunities related to utilization review.
  • Maintained professional competence by staying current on industry trends, best practices, and regulatory requirements specific to utilization review nursing.
  • Improved patient care quality by conducting thorough utilization reviews and making recommendations for optimal treatment plans.
  • Supported data-driven decision-making by regularly analyzing trends in resource utilization, identifying opportunities for improvement, and implementing best practices.
  • Obtained authorizations from multiple insurance carriers for various levels of care.
  • Enhanced patient satisfaction by collaborating with interdisciplinary teams to develop individualized care plans, ensuring appropriate level of care.
  • Managed patients recovering from medical or surgical procedures.
  • Supervised and maintained all utilization review documentation through internal software.
  • Ensured compliance with regulations and accreditation standards by maintaining accurate documentation of all utilization review activities.
  • Facilitated therapeutic communication, conflict resolution and crisis intervention by redirecting negative behaviors and helping patients regain or improve coping abilities.
  • Streamlined the case management process by effectively prioritizing high-risk cases for timely intervention and followup.
  • Performed prior authorization review of services requiring notification.
  • Served as a vital liaison between patients, healthcare providers, and insurance companies, fostering effective communication and coordination among all parties involved in the care process.
  • Collaborated with leadership to devise initiatives for improving nursing satisfaction, retention and morale.
  • Submitted cases for criteria failures and helped facilitate resolutions and approvals.
  • Offered exceptional care and support to individuals recovering from acute incidents and dealing with chronic conditions.
  • Supported organizational growth and development through effective collaboration with interdisciplinary teams focused on improving the quality, safety, and efficiency of healthcare delivery.
  • Reduced healthcare costs through efficient utilization of resources and identification of unnecessary treatments or procedures.
  • Followed all personal and health data procedures to effectively comply with HIPAA laws and prevent information breaches.
  • Participated in evidence-based practice project implementation, nursing competency development and nursing simulation activities.
  • Evaluated medical guidelines and benefit coverage to determine appropriateness of services.
  • Promoted positive outcomes with proactive assessment of patients'' needs and development of targeted interventions to address identified barriers to recovery.
  • Facilitated workgroup meetings with medical personnel to find effective solutions to issues.
  • Demonstrated commitment to ethical practice by upholding patient confidentiality and advocating for individual rights in all interactions with stakeholders.
  • Equipped patients with tools and knowledge needed for speedy and sustained recovery.
  • Used first-hand knowledge and clinical expertise to advocate for patients under care and enacted prescribed treatment strategies.
  • Participated in performance improvement initiatives designed to enhance service delivery while maintaining fiscal responsibility.
  • Communicated with healthcare team members to plan, implement and enhance treatment strategies.
  • Leveraged feedback and process improvement opportunities to create safer and healthier environment and increase patient satisfaction.
  • Increased staff efficiency by providing ongoing education on proper documentation techniques necessary for accurate claims processing.
  • Collaborated with insurance companies to verify coverage, clarify benefits, and facilitate authorization for medical services, reducing delays in patient care delivery.
  • Evaluated patient histories, complaints, and current symptoms.
  • Reported findings to quality departments after conducting routine restraint audits and worked with team to devise corrective actions for deficiencies.
  • Delivered high level of quality care to diverse populations while overseeing patient admission and triaging based on acuity and appropriate department admission.
  • Gained extensive knowledge in data entry, analysis and reporting.
  • Excellent communication skills, both verbal and written.
  • Developed strong organizational and communication skills through coursework and volunteer activities.
  • Organized and detail-oriented with a strong work ethic.
  • Identified issues, analyzed information and provided solutions to problems.
  • Proven ability to develop and implement creative solutions to complex problems.
  • Assisted with day-to-day operations, working efficiently and productively with all team members.
  • Proven ability to learn quickly and adapt to new situations.
  • Provided professional services and support in a dynamic work environment.
  • Passionate about learning and committed to continual improvement.
  • Gained strong leadership skills by managing projects from start to finish.
  • Worked well in a team setting, providing support and guidance.
  • Delivered services to customer locations within specific timeframes.
  • Managed time efficiently in order to complete all tasks within deadlines.
  • Skilled at working independently and collaboratively in a team environment.

Education

Bachelor of Science - Leadership-(Bachelor's Degree in Process)

Northwestern University
Evanston, IL
02.2025

Associate of Applied Science - Microsoft 07 Class & General Nursing discourse and cohorts

Purdue University
Hammond, IN
12.2010

Completed general & nursing pre-requisites courses

South Suburban College
01.2006

Associate of Applied Science - LPN School & Additional Nursing Pre-requisites

Triton College
River Grove, IL
01.2000

Associates - Phlebotomy, Nursing pre-requisites, and Certified Nursing Assistant

College of Lake County
Grayslake, IL
01.1997

Certificate - Delirium and Dementia

NurseCe4Less continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation
02.2024

Certification - Treating Six Forms of Anxiety

The Institute for Brain Potential
03.2023

CEU completion - Head Trauma: Pathophysiology, Treatment, and Rehabilitation. Screening Guideline and Preventative Healthcare Programs

NurseCe4Less continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation, provider number P0349
08.2023

Certificate - Medical Billing and Coding

Condensed Curriculum International
12.2010

Certificate - Leadership Principles

Harvard Business School
04.2021

Skills

  • Interdisciplinary Collaboration
  • Quality Improvement
  • Staff Development
  • Care Plan Development
  • Clinical Leadership
  • Healthcare Administration
  • Effective Communication
  • Policy Implementation
  • Infection Control
  • Resource Allocation
  • Regulatory Compliance
  • Patient Care Management
  • Performance Evaluation
  • Conflict Resolution
  • Stress Management
  • Ethical Decision-Making
  • Time Management
  • Nursing Supervision
  • Medication Administration
  • Problem Solving
  • Delegation Skills
  • Team Building
  • Organizational Skills
  • Wound Care Management
  • Active Listening
  • Critical Thinking
  • Empathy and Compassion
  • Decision Making
  • Clinical Resources Management
  • Personnel Evaluations
  • Work Planning and Prioritization
  • Direct Patient Care
  • Accreditation Coordination
  • Goal Planning
  • HIPAA Regulations
  • Nurse Education and Training
  • Documentation and Reporting
  • Policy Development
  • Profitability Strategies
  • Issue Resolution
  • Relationship Building
  • Multidisciplinary Team Collaboration
  • Clinical Operations Management
  • Policies Compliance Enforcement
  • Process Improvements
  • Recruiting and Hiring
  • Multidisciplinary Collaboration
  • Chronic Disease Management
  • Employee Coaching
  • Process Improvement
  • Quality Control
  • Acute Care
  • Effective Multitasking
  • Disease Control
  • Emergency Response
  • Quality Assurance
  • Risk Management
  • Long-Term Care

Websites

Accomplishments

  • Supervised team of 50 staff members as an ADON.
  • Documented and resolved Telehealth case management ideas which led to the development of the Blood Pressure Remote Patient Monitoring (BPRPM) program.
  • Achieved in retaining Telehealth patient, provider and facility contracts through effectively helping develop and create the BPRPM program.

Certification

  • 02/2012, Present, Head Trauma: Pathophysiology, Treatment, and Rehabilitation. Screening Guideline and Preventative Healthcare Programs, NurseCe4Less continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation
  • Implicit Bias and Sexual Prevention
  • Treating Six Forms of Anxiety Certification
  • Business and Entrepreneurship Life Coach certificate
  • Health and Nutrition Life Coach certificate
  • Therapeutic Art Life Coach certificate
  • Harvard Leadership certificate
  • LTV-950 refresher course
  • CPR for adults and pediatrics
  • Introduction to Healthcare Quality

Linkedin2

https://www.linkedin.com/in/beverlyn-robert-77411b207/

Email2

BeverlynKelly-Robert2020@u.northwestern.edu

Awards

  • Member: Triton Dean’s Honor List and College Secretary of Pacemaker’s Club, 1997-2000.
  • Member: College of Lake County College Honor List and Alumni Association GPA: 3.00, 1997- Present.

Spending quality time with my family, knitting, and scuba diving.

I love being the best wife and mother that I can be to my family. I enjoy sitting calmly and knitting. Knitting is my downtime. And, I enjoy the adventures of discovering the beautiful oceans when I have the time. 

Languages

Spanish
Full Professional

Timeline

ADON & Telehealth Chronic Nurse Case Manager

Precise Telehealth, Inc.
09.2018 - 12.2023

Utilization Management Specialist

NextLevel Health Partners
08.2016 - 08.2018

Utilization Management Specialist and Transition of Care Coordinator

Family Health Network
02.2011 - 07.2016

Worker’s Compensation Utilization Review Nurse & Nurse Case Manager

Triune Health Group, Inc.
02.2010 - 02.2011

Worker’s Compensation Utilization Review Specialist

Rising Medical Solutions
09.2008 - 09.2009

Utilization Review Nurse

WellPoint/ WellCare Health Insurance Services
09.2006 - 09.2008

Bachelor of Science - Leadership-(Bachelor's Degree in Process)

Northwestern University

Associate of Applied Science - Microsoft 07 Class & General Nursing discourse and cohorts

Purdue University

Completed general & nursing pre-requisites courses

South Suburban College

Associate of Applied Science - LPN School & Additional Nursing Pre-requisites

Triton College

Associates - Phlebotomy, Nursing pre-requisites, and Certified Nursing Assistant

College of Lake County

Certificate - Delirium and Dementia

NurseCe4Less continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation

Certification - Treating Six Forms of Anxiety

The Institute for Brain Potential

CEU completion - Head Trauma: Pathophysiology, Treatment, and Rehabilitation. Screening Guideline and Preventative Healthcare Programs

NurseCe4Less continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation, provider number P0349

Certificate - Medical Billing and Coding

Condensed Curriculum International

Certificate - Leadership Principles

Harvard Business School

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