Carolyn Husted
Rancho Cordova
Summary
Strategic professional in business operations known for high productivity and efficiency in task completion. Specialize in process optimization, project management, and data analysis, ensuring streamlined workflows and enhanced operational efficacy. Excel in communication, problem-solving, and leadership, leveraging these soft skills to drive team success and achieve organizational goals.
Overview
26
26
years of professional experience
1
1
Certification
Work History
Lead Consultant Facility Compliance Review
Blue Shield
Ranch Cordova, CA
01.2019 - Current
- Performs audits on hospital claims for appropriate billing and contract compliance
- Assist with legal preparations and consulting
- Lead coaching and training of staff
- Maintain the updating of desk level procedures and workflows
- Perform Monthly Nurse audits for accuracy
- Lead special projects
- Assist manager with Cost of Health Care Initiatives
- Facilitate and Lead meetings
Interim Lead of Appeals and Grievances
Blue Shield
El Dorado Hills, CA
01.2017 - 01.2019
- Responsible for investigating and processing the most complex grievances and appeals requests from members, providers and our regulatory department
- Serves as technical resource to team and may be assigned to work on projects impacting development, interpretation, and implementation of medical policy or other managed care initiatives
- Provides direction and collaborates with non-clinical leadership and staff throughout the appeal process
- Works with medical directors regarding process improvements
- Responsible for team as overall SME and support
- Contributed to development of goals and planning efforts in regard to inventory management and improving overall processes
- As the acting Lead, I have enhanced computer proficiency with Microsoft office, excel, and basic power point
- Assisted training new staff with coaching and training
- Experienced the process of being involved with a deposition
- As acting Lead, I was able to greatly improve my communication skills, time management, and multitasking skills overall
Staff RN of Appeals and Grievances
Blue Shield
El Dorado Hills, CA
01.2016 - 01.2017
- Conducts investigations and reviews of member and provider medical necessity appeals
- Reviews prospective, inpatient, or retrospective medical records of denied services for medical necessity
- Extrapolates and summarizes medical information for medical director consultants and other external review
- Prepares recommendations to either uphold or deny appeal and forwards to Medical Director for approval
- Ensures that appeals and grievances are resolved timely to meet regulatory timeframes
- Documents and logs appeal/grievance information on relevant tracking systems and mainframe system
Nurse Auditor, Facility Compliance Review
Blue Shield
El Dorado Hills, CA
01.2011 - 01.2016
- Performs clinical reviews and provides approval determination for members using BSC evidenced based guidelines
- Conducts review activities with delegated entities as necessary and member treatment in order to meet BSC Medical Policy, Contract Compliance for Stop Loss and Disallowed charges and appropriate delivery of care
- Performs critical in-depth analysis of medical records for appropriateness of care and level of care using Milliman Care Guidelines
- Responsible for helping revise DLP's and Workflows
- Provided some education and training to new staff
- Requires good time management for daily production requirements and extra projects
Oncology Nurse
Sierra Hematology Oncology
Carmichael, CA
08.2007 - 08.2011
- Responsible for accessing patients through ports, picc lines and intravenously
- Preparation of numerous combinations of chemotherapy medications: knowledge of calculations
- Responsible for scheduling of all appointments for patients
- Responsible for all explanations or questions to patients about chemotherapy medications and side effects; assists with alleviating secondary problems associated with chemotherapy treatment and cancer
Triage Nurse
Kaiser Call Center
Sacramento, CA
01.2006 - 01.2007
- Responsible for answering incoming phone calls
- Data entry of information provided by caller
- Used protocols and scripts provided by computer to access description of illness/problem
- Triaged members to determine appropriate outcome of their illness/problem
Charge Nurse- Registered Nurse
Blood Source
Sacramento, CA
01.2000 - 01.2002
- Responsible for all aspects of blood drive, including supervision of staff and any problems or questions involving donors and /or staff
- Responsible for reviewing, correcting, and signing off all donor evaluations
- Assisted with difficult or challenging phlebotomies
Student Nurse Extern- Oncology Department
UC Davis Medical Center
Sacramento, CA
01.1999 - 01.2000
- Responded to acutely ill patients by assisting staff and physicians during advanced procedures
- Responsible for activities of daily living for patients and facilitated in self learning of nurse duties
Education
Certified in Advanced Botox and Fillers -
National Laser Institute
01.2024
A.S. - Nursing
American River College
Sacramento, CA01.2000
A.A. - Liberal Arts
Sierra College
Rocklin, CA01.1998
Skills
- Sensitive skin care
- Lunch time chemical peel
- dermal filler training
- Aesthetic treatment planning
- Medical-grade skincare proficiency
- Botox administration proficiency
- Facial anatomy comprehension
Certification
National Laser Institute, Certified in Advanced Botox and Fillers, 2024
Training
- Bedside Cardiac Assessment
- Basic EKG Interpretation
- IV Certification
- Current Basic Life Support
Timeline
Lead Consultant Facility Compliance Review
Blue Shield
01.2019 - Current
Interim Lead of Appeals and Grievances
Blue Shield
01.2017 - 01.2019
Staff RN of Appeals and Grievances
Blue Shield
01.2016 - 01.2017
Nurse Auditor, Facility Compliance Review
Blue Shield
01.2011 - 01.2016
Oncology Nurse
Sierra Hematology Oncology
08.2007 - 08.2011
Triage Nurse
Kaiser Call Center
01.2006 - 01.2007
Charge Nurse- Registered Nurse
Blood Source
01.2000 - 01.2002
Student Nurse Extern- Oncology Department
UC Davis Medical Center
01.1999 - 01.2000
Certified in Advanced Botox and Fillers -
National Laser Institute
A.S. - Nursing
American River College
A.A. - Liberal Arts
Sierra College
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