Summary
Overview
Work History
Education
Skills
Timeline
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Carrie Holmes

Murrells Inlet,SC

Summary

Strong leader and problem-solver dedicated to streamlining operations to decrease costs and promote organizational efficiency. Fosters a positive workplace environment amongst a wide variety of teams. Uses independent decision-making skills and sound judgment to positively impact the organization.

Overview

15
15
years of professional experience

Work History

Director II Medical Mgmt

Anthem
04.2022 - Current
  • Oversight of Utilization Management, Care Transition Intervention and multiple Business Change Managers
  • Improved program efficiency with strategic planning and resource allocation that focus on the member, teams and organization.
  • Secured key partnerships that contributed to the growth strategy and market reach.
  • Analyze data results and preparation for executive presentation.
  • Developed high-performing teams by providing mentorship, guidance, and opportunities for professional growth.
  • Enhanced team collaboration through regular communication, goal setting, and performance evaluations.
  • Projection of Staffing needs while maintaining fiscal responsibility.

Mgr II Medical Mgmt

Anthem
07.2020 - 04.2022
  • Managed a team built of clinicians and non-clinicians to provide utilization management for Medicare Advantage members.
  • Increased team productivity by implementing streamlined processes and effective communication strategies.
  • Remained compliant with CMS Turnaround Times by developing and executing strategic plans and performance metrics.
  • Created positive & collaborative relationships with facilities and providers for care coordination.
  • Enhanced provider satisfaction by resolving escalations promptly and maintaining open lines of communication.

Nurse Medical Mgmt Team Lead

Anthem
10.2018 - 07.2020
  • Provide detailed assignments for both RNs and Non-clinical staff.
  • Accurately track flash reports and YTD statistics.
  • Performs audits to ensure the team is adhering to medical policies and cost of care initiatives.
  • Participate in the interview and hiring process.
  • Track errors and provide re-education.
  • Participate in facility meetings and promote positive relationships for successful care coordination.
  • Collaborate with manager to streamline processes and implement initiatives.
  • Team mentor and top resource (SME) for difficult situations and questions.
  • Collaborated in creating and maintaining a positive work environment for the team.

Nurse Medical Mgmt II & Sr

Anthem
07.2012 - 10.2018
  • Collaborated with interdisciplinary teams for optimized patient treatment plans and outcomes.
  • Make clinical based decisions regarding acute inpatient hospital stays using MCG Care Guidelines for both DRG and Non-DRG facilities.
  • Participates in discharge planning as well as concurrent reviews for members.
  • Accurately applies the appropriate ICD10 codes.
  • Provides coverage for team lead
  • Works closely with management to help appropriately adjust processes
  • Serves as a mentor for new nurses
  • Able to communicate professionally with providers and maintain a positive relationship

Appeals Coordinator

Zoll
07.2011 - 07.2012
  • Collaborated with cross-functional teams, resulting in improved communication and quicker resolutions.
  • Responsible for overturning insurance denials for multiple payers.
  • Uses technical writing to create an individual appeal letter signifying medical necessity.
  • Participates in the prior authorization submission and follow up.
  • Utilization Review for Medicare patients
  • Claim review
  • Accurately uses the ICD-9 coding system
  • Responsible for training new employees

Registered Nurse

UPMC
05.2009 - 12.2011
  • Primarily worked on the Intermediate Care Unit however flexed to other nursing floors when necessary.
  • Worked as part of a multi-disciplinary team for the patients overall well-being.
  • Responsible for safe and effective discharge planning.
  • Conducted thorough patient assessments to identify changes in condition, promptly notifying physicians and initiating appropriate interventions when necessary.
  • Promoted a culture of safety within the healthcare facility by participating in quality improvement initiatives, identifying potential hazards, and advocating for best practices in nursing care delivery.
  • Skillfully managed challenging patient situations using de-escalation techniques, crisis intervention strategies, and therapeutic communication skills.
  • Utilized critical thinking skills to prioritize nursing interventions based on patients'' acuity levels and individual needs.

Education

Bachelor of Science - Nursing

Duquesne University
Pittsburgh, PA
05.2010

Skills

  • Exceptional Communication
  • People Leader Management
  • Project Coordination
  • Problem Solving & Analytical Skills
  • Influential Letter Writing to Professional Organizations

Timeline

Director II Medical Mgmt

Anthem
04.2022 - Current

Mgr II Medical Mgmt

Anthem
07.2020 - 04.2022

Nurse Medical Mgmt Team Lead

Anthem
10.2018 - 07.2020

Nurse Medical Mgmt II & Sr

Anthem
07.2012 - 10.2018

Appeals Coordinator

Zoll
07.2011 - 07.2012

Registered Nurse

UPMC
05.2009 - 12.2011

Bachelor of Science - Nursing

Duquesne University

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Carrie Holmes