Chandra Hatten
San Marcos,Tx
Summary
Licensed Vocational Nurse with 20 years in healthcare industry and 17 years specializing in Utilization Review/Management/Medical Necessity appeals considered critical thinker and problem-solver due to dynamic patient care planning and understanding of Medicare/Medicaid guidelines. Known for having great rapport with providers and insurance carriers.
Overview
19
19
years of professional experience
Work History
Appeals Nurse Senior
Amerigroup (Anthem/Elevance Health)
01.2023 - 12.2023
- All of the below noted responsibilities of an appeals nurse with the addition of being the point of contact for all Texas Appeals Nurses (4 RNs) and one clinical analyst for all things related to the correct processing of appeals cases
- Also served as first point of contact for all other departments with questions regarding the appeals process
- Ensuring that the team stays within turn around times and passing all state audits
- Assisting Team Lead and Manager with reports and attending meetings.
- Responsible for training new appeals nurses and appeals triage analyst
Appeals Nurse
Amerigroup (Anthem/Elevance Health)
04.2015 - 12.2022
- Review of clinical information from multiple inpatient and outpatient providers on previously denied services for medical necessity using McKesson Interqual criteria through 09/2019 and McMillan Criteria from 09/2019 forward for inpatient admissions
- For pre service appeals TMHP criteria as well as outside vendor criteria (Carelon) and Amerigroup/Anthem criteria reviewed
- For cases previously denied by Medical Director, a synopsis of medical necessity composed from reviewed clinical and routed to Medical Director for decision
- Upon Medical Director decision, the decision reviewed for accuracy and decision letter generated
- Gathered all case documentation including clinical, criteria, utilization management denial letter, case scenario, and Medical director provided questions and forwarded to third party contractors (MCMC and MES) for like specialty MD review requests
- For cases previously denied for administrative decisions (failure to pre authorize, late notification, spell of illness, not a covered benefit) case reviewed to determine if administrative denial was per policy and render determination of uphold or overturn
- Contact members and providers on a regular basis to obtain clinical, explain appeals processes, and advise of determinations
- Refer members to member advocates and case management when condition or situation shows a need
- Often confer with Inpatient Concurrent Review, Precertification, Member advocates, Case Management and outside vendors regarding members and mistakes in processes made within other departments
- Generate all decision letters to be mailed.
Outpatient Precertification Nurse
Amerigroup (Anthem/Elevance Health)
03.2014 - 04.2015
- Review of clinical information from multiple outpatient providers to determine medical appropriateness of outpatient physical, occupational and speech therapy requests using McKesson Interqual criteria as well as company guidelines
- Routed cases to medical director for decision when criteria is not met
- Assisted in entering case shells from faxes coming in from multiple providers for all outpatient services.
Utilization Management Inpatient Concurrent Review Nurse
Amerigroup (Anthem/Elevance Health)
05.2012 - 03.2014
- Review of clinical information from multiple per diem and DRG inpatient facilities to determine medical appropriateness of inpatient admission and level of care using McKesson Interqual criteria
- Discussing patients in depth with Medical Director during rounds and routing to Medical Director for decision when criteria is not met
- Evaluation of patient’s needs throughout the admission to ensure the discharge plan is correct in order to refer to the correct outpatient programs and services.
Utilization Review Nurse
HealthHelp, Inc
05.2006 - 09.2011
- Reviewing clinical information by phone or fax from multiple physician offices and facilities seeking to obtain pre-authorizations for Pacemakers, Cardiac Catheterizations, CT, CTA, MRI, MRA, PET, PET stress, SPEC stress tests, and Radiation Therapy
- Determining medical necessity based on clinical information given by physician office compared to criteria set forth by physicians within the company
- Education to physician office regarding radiation exposure and preferred testing based on clinical information
- Send procedures to medical review if medical necessity is not met.
Nurse Manager
Baylor College of Medicine
08.2005 - 05.2006
- Acquiring medical history from patient; Obtaining chief complaint for visit; Rooming patients; Patient teaching on Safe sex, Birth control, teen pregnancy, nutrition, and medications prescribed by doctor; Monthly reports for VFC, City of Houston, Department of Health, and Baylor College of Medicine; Obtaining Labs specified by doctor; referrals for special procedures; and patient follow up calls.
Office Nurse
Texas Children’s Pediatric Associates
09.2004 - 08.2005
- Rooming patients, Deciphering and carrying out doctors orders including: immunizations, finger and heel sticks, CBCs, PKUs, rapid strep tests, rapid flu tests, rapid RSV tests, urinalysis, catheters, tympanogram, oae, hearing and vision screening, triage phone calls, calling in prescriptions, and contacting patients to check status
Education
Graduated -
Needville High School
Licensed Vocational Nursing Program at Polly Ryon Memorial Hospital - Licensed Vocation Nursing
Wharton County Junior College
08.2004
Course of studies concentrated on subjects in the Medical Field -
Wharton County Junior College
05.2003
Course of studies concentrated on subjects in the Business and Secretarial Field -
Wharton County Junior College
05.1994
Skills
- Licensed by Texas nursing board Multistate compact LVN license License number 194973
- Medicaid knowledge
- Utilization review
- Utilization Management
- Microsoft Office
- Supervision and leadership
- Milliman Guidelines
- InterQual Guidelines
- Managed Care
- Training staff
- Microsoft Office
- Prior Authorization
- Appeals Process Proficiency
- Regulatory Compliance Adherence
Timeline
Appeals Nurse Senior
Amerigroup (Anthem/Elevance Health)
01.2023 - 12.2023
Appeals Nurse
Amerigroup (Anthem/Elevance Health)
04.2015 - 12.2022
Outpatient Precertification Nurse
Amerigroup (Anthem/Elevance Health)
03.2014 - 04.2015
Utilization Management Inpatient Concurrent Review Nurse
Amerigroup (Anthem/Elevance Health)
05.2012 - 03.2014
Utilization Review Nurse
HealthHelp, Inc
05.2006 - 09.2011
Nurse Manager
Baylor College of Medicine
08.2005 - 05.2006
Office Nurse
Texas Children’s Pediatric Associates
09.2004 - 08.2005
Graduated -
Needville High School
Licensed Vocational Nursing Program at Polly Ryon Memorial Hospital - Licensed Vocation Nursing
Wharton County Junior College
Course of studies concentrated on subjects in the Medical Field -
Wharton County Junior College
Course of studies concentrated on subjects in the Business and Secretarial Field -
Wharton County Junior College
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