Open To Work
Charlene Defee
Registered Nurse
Effingham,SC
Summary
Experienced healthcare professional with a strong background in utilization management and quality assurance. Proficient in performing detailed assessments and maintaining compliance with established standards, resulting in better patient outcomes and operational effectiveness. Focused on care coordination and clinical assessment, with a proven track record of improving patient care and regulatory compliance.
Overview
26
26
years of professional experience
Work History
Utilization Management Compliance Team
McLeod Regional Medical Center
Florence, SC
10.2017 - Current
- Conducted utilization reviews, concurrent reviews, authorization requests, and discharge planning to ensure compliance with established guidelines.
- Evaluated medical necessity and cost-effectiveness of services via utilization review processes.
- Performed pre-certification, concurrent, and retrospective reviews of inpatient services.
- Evaluated prior authorization requests for accuracy and completeness prior to submission to payer.
- Contacted insurance carriers to obtain authorizations for services delivered to patients.
- Escalated cases to secondary review for non-compliance with criteria.
- Collaborated with healthcare providers to ensure appropriate level of care was provided in a cost-effective manner.
- Communicated regularly with physicians and providers regarding appropriateness of care delivery within established parameters.
- Performed thorough assessments of patient records to verify medical necessity and adherence to healthcare regulations.
- Evaluated treatment progress by analyzing medical records, lab results, and physician notes to support quality care decisions.
- Ensured compliance with organizational policies and procedures related to utilization management processes.
- Interpreted and evaluated diagnostic tests to identify and assess patient's condition.
Home Health Regional Administrator
Pruitt Home Health
Florence , SC
07.2014 - 06.2016
- Managed staff schedules and assignments to optimize resource allocation effectively.
- Coordinated care plans with multidisciplinary teams to ensure quality service delivery.
- Oversaw daily operations of home health services for diverse patient populations.
- Implemented compliance protocols to meet regulatory requirements in home health care.
- Evaluated patient progress and adjusted care plans based on individual needs and feedback.
- Evaluated existing processes within the organization on an ongoing basis in order to identify opportunities for improvement or cost savings measures.
- Conducted regular meetings with staff members to discuss performance issues and identify areas for improvement.
- Established relationships with external stakeholders such as healthcare providers, insurance companies, and other organizations to facilitate efficient delivery of services.
- Collaborated with medical professionals to develop individualized treatment plans for patients based on their needs.
- Supervised the daily operations of the home health agency, including staffing, scheduling, budgeting, and customer service.
- Reviewed patient charts regularly to ensure accuracy of documentation according to established standards.
- Collaborated with healthcare providers to coordinate additional services for clients.
- Led team meetings to discuss client progress, staff performance, and operational improvements.
- Maintained communication and transparency with governing boards, department heads and medical staff.
- Maintained awareness of government regulations, health insurance changes and financing options.
RN Case Manager
Alere Health
Remote, SC
12.2010 - 02.2013
- Identified high-risk cases requiring intensive monitoring or specialized interventions.
- Coordinated medical services between primary care providers, specialists, hospitals and outpatient clinics.
- Assessed patient needs through comprehensive health evaluations.
- Documented patient interactions and care updates, ensuring accurate and timely information in electronic systems.
- Supported patients in navigating insurance and healthcare services, enhancing their access to needed resources.
- Educated patients on disease prevention strategies, wellness promotion techniques and lifestyle modifications.
- Developed educational materials for patients on managing chronic conditions.
- Facilitated referrals to community resources, connecting patients with additional support services to address their needs.
Home Health Clinical Manager
Tri County Home Health
Sumter, South Carolina
08.2009 - 12.2010
- Supervised home health staff, ensuring adherence to care standards and enhancing patient safety.
- Coordinated patient care plans with healthcare providers and families.
- Conducted regular performance evaluations of clinical staff, fostering professional development and improving care quality.
- Ensured quality assurance of patient care by conducting regular reviews of medical records for accuracy and completeness.
- Facilitated effective communication among all disciplines involved in providing home health care services.
- Responded to inquiries from patients, families and referral sources regarding clinical issues or concerns.
- Provided oversight of personnel, including hiring, training, scheduling and performance evaluations.
- Performed annual competency assessments for all clinical staff members.
- Conducted regular home visits to assess client needs and ensure quality of care.
- Coordinated with insurance companies to verify coverage and process claims for home care services.
- Monitored and maintained compliance with state and federal regulations for home care services.
- Maintained communication and transparency with governing boards and department heads, facilitating informed decision-making on clinical practices.
Home Health RN Case Manager
Carolinas Hospital System Home Health
Florence, SC
11.2000 - 06.2008
- Assessed patient needs and developed individualized care strategies.
- Monitored patient progress and adjusted care plans accordingly.
- Educated patients and families on health management and treatment options to empower self-care and enhance health outcomes.
- Advocated for patients' needs within the healthcare system to ensure access to necessary resources and support.
- Conducted regular follow-up visits to evaluate patient progress toward care plan goals and adjust strategies.
- Provided comprehensive nursing care for patients in their homes.
- Provided emotional support for patients experiencing difficult diagnoses or transitions from hospital to home setting.
- Collaborated with physicians to develop treatment plans that met the needs of each patient.
- Recognized when a change in condition warrants further evaluation or intervention and took appropriate action.
- Educated patients and families about treatments, medications, and self-care management techniques.
- Adapted teaching methods based on individual learning styles while providing education on disease processes and self-management strategies.
- Responded quickly to emergency situations involving acute illness or injury.
- Evaluated the effectiveness of interventions by monitoring changes in patient's condition or behavior over time.
- Addressed patient care needs, collected vitals, dressed wounds, and managed catheters.
- Maintained accurate documentation of assessments, treatments, medications, and progress notes in accordance with agency policies.
- Utilized electronic health records to document patient care accurately and comprehensively.
- Managed the administration of intravenous (IV) therapies and nutrition.
Education
Associate Degree in Nursing - Nursing
Florence-Darlington Technical College
Florence, SC05-2000
Skills
- Self-Directed
- Analytical thinking
- Critical thinking
- Dependable and responsible
- Communication
- Quality improvement
- Utilization review
- Discharge planning
- Home health care
- Compliance procedures
Timeline
Utilization Management Compliance Team
McLeod Regional Medical Center
10.2017 - Current
Home Health Regional Administrator
Pruitt Home Health
07.2014 - 06.2016
RN Case Manager
Alere Health
12.2010 - 02.2013
Home Health Clinical Manager
Tri County Home Health
08.2009 - 12.2010
Home Health RN Case Manager
Carolinas Hospital System Home Health
11.2000 - 06.2008
Associate Degree in Nursing - Nursing
Florence-Darlington Technical College