Charlotte Jackson
Lancaster
Summary
Dedicated and performance driven Registered Nurse with effective experience in utilization management, case management, home health nursing, skilled nursing, staff development/preceptor, and quality assurance executing clinical coordination strategies to meet company objectives. Top-Performing clinical associate in Utilization Review and Case Management for the past 18 years.
Overview
38
38
years of professional experience
1
1
Certification
Work History
Utilization Nurse Manager 2/RN Care Manager
HUMANA INC
07.2016 - Current
- Manage network participation, care with specialty networks, care with DME providers, and redirection to alternate levels of care if needed.
- Recommend services for Humana plan members utilizing care alternatives available within the community and nationally.
- Review medical records for medical necessity, identify potentially unnecessary services, and recommend alternatives as appropriate by analyzing clinical protocols, NCDs, LCDs, policies, and MCG criteria.
- Examine clinical program’s information to identify members for specific case management and/or disease management interventions by utilizing established screening criteria.
- Utilizes clinical expertise and medical resources to interpret medical records and test results, and provide assessments accordingly.
- Meets monthly production requirements and quality assessment (QA) requirements to ensure a quality product.
- Conducts admission reviews, post-discharge calls, and discharge planning.
- Participates in the UR review process which includes prospective reviews.
LTSS Correspondence RN
AmeriHealth Caritas
08.2023 - 07.2025
- Drafts correspondence letters based on review outcomes in accordance with National Committee for Quality Assurance (NCQA) standards.
- Works with senior management to identify and implement opportunities for improvement.
- Contributes to correspondence letter template creation and maintenance with the correspondence team.
- Collaborates with UM review team to ensure turnaround times (TATs) are within organizational compliance standards.
Preservice Review RN
Optum, UHC Group
02.2022 - 05.2023
- Review/interpret clinical/medical records submitted from provider (office records, test results, prior operative reports.
- Identify missing information from clinical/medical documentation, and request additional medical or clinical documentation as needed (LOI process, phone/fax).
- Review and validate diagnostic/procedure/service codes to ensure their relevance and accuracy as applicable (InterQual, PNL list, EPAL list, policies, LCDs, NCDs).
- Identify and validate usage of nonstandard codes, as necessary (generic codes, unlisted codes).
- Make determinations per relevant protocols, as appropriate (approval, denial process).
Registered Nurse, Float Pool
HealthSouth Rehabilitation Hospital of Arlington
06.2013 - 12.2014
- Served as a resource for other nurses on the Float Pool, offering guidance on policies, procedures, and best practices.
- Mentored new nursing staff, sharing best practices for patient care and fostering a supportive team atmosphere.
- Strengthened relationships between nursing teams across various units through regular collaboration on shared float pool initiatives and projects.
- Facilitated smooth transitions between shifts by providing thorough handoff reports to incoming nurses, ensuring continuity of care.
Complex Case Manager
Aetna
10.2012 - 07.2014
- Responsible for utilizing a collaborative process of assessment, planning, facilitation, and advocacy for options and services to meet an individual’s benefit and/or healthcare needs through communication and available resources to promote optimal cost-effective outcomes for the designated Managed Care program.
- Implemented mentoring/training for Case Management staff.
- Managed case load assignments, utilization review referrals, and productivity metrics.
- Developed and maintained strong working relationships with both internal and external stakeholders, peers, and management.
- Responsible for developing and coordinating medical management strategies to facilitate a individualized care plans with a focus on quality/cost effective treatment alternatives and resources.
Condition Management Coordinator II
Blue Cross Blue Shield of Texas
04.2007 - 06.2012
- Triaged and assess members for BCBSTX wellness education programs and provide pre-admission counseling, post-op discharge assessments, and disease management when appropriate.
- Obtained consent and conduct comprehensive case management assessment and referral for those members meeting CM criteria, and ensure enrollment in the disease management program as appropriate.
- Ordered durable medical equipment (DME), prepare negotiated rate letters for diabetic education, and physician collaboration for chronic conditions.
- Present cases to the medical director and team of nurses.
- Educate and orient new nurses to work processes and standard operating procedures.
RN Floor/Charge Nurse
Veterans Administration (VA) Hospital
08.2004 - 08.2006
- Responsible for providing direct patient care to inpatients.
- Supervised care provided by LPNs and CNAs.
- Communicated appropriate information with interdisciplinary team.
- Assessed and reassessed patients, creating individualized plan of care.
RN Field Case Manager
Interim Home Health
04.2003 - 07.2005
- Initiated, implemented and supervised the clinical care plan of home bound patients.
- Conducted and implemented patient care assessments and care plans for Medicare, Medicaid and private insurance covered individuals.
- Conducted supervisory and preceptor visits for LPN’s and Certified Nursing Assistants.
- Responsible for Point of Care OASIS documentation for in home admissions, re-certifications, discharges, medication profiles and case conferences.
E-4 Material Control Specialist
US Army Reserve
09.1987 - 03.1993
- Improved material availability for production teams, maintaining optimal stock levels through regular monitoring.
- Supported internal audits of warehouse operations, ensuring compliance with company policies as well as relevant industry regulations and best practices.
- Implemented effective cycle counting procedures, resulting in reduced discrepancies between physical inventory and system records.
Education
Certified Case Manager -
Commission For Case Manager Certification
Master of Science - Nursing, RN
Chamberlin College of Nursing
01.2017
Bachelor of Science - Nursing, RN
Chamberlin College of Nursing
01.2014
Associate of Science - Nursing, RN
Delgado Charity School of Nursing
01.2002
Skills
- Microsoft Office Outlook, Microsoft Excel and Word
- Microsoft PowerPoint and Microsoft Windows
- Adobe Acrobat
- UR and CM documentation platforms
- Team Builder
- Mentor/Preceptor
- Cross Functional Collaboration
- Policy and Process Implementation
- Performance/Quality Improvement
- Clinical Advisor
Accomplishments
- NLP Annotation Champion NLP Adoption 2024
- IRR Question Validator 2023
- Home Health Provider Liaison 2016
- Behavioral Health Collaboration 2016
- PERS (Personal Emergency Program) 2015
- LEGAL NURSE CONSULTANT TRAINING COURSE The Center for Legal Studies Studies 2014
Certification
Texas, Compact Licensure License #735760
Languages
English
Full Professional
Timeline
LTSS Correspondence RN
AmeriHealth Caritas
08.2023 - 07.2025
Preservice Review RN
Optum, UHC Group
02.2022 - 05.2023
Utilization Nurse Manager 2/RN Care Manager
HUMANA INC
07.2016 - Current
Registered Nurse, Float Pool
HealthSouth Rehabilitation Hospital of Arlington
06.2013 - 12.2014
Complex Case Manager
Aetna
10.2012 - 07.2014
Condition Management Coordinator II
Blue Cross Blue Shield of Texas
04.2007 - 06.2012
RN Floor/Charge Nurse
Veterans Administration (VA) Hospital
08.2004 - 08.2006
RN Field Case Manager
Interim Home Health
04.2003 - 07.2005
E-4 Material Control Specialist
US Army Reserve
09.1987 - 03.1993
Master of Science - Nursing, RN
Chamberlin College of Nursing
Bachelor of Science - Nursing, RN
Chamberlin College of Nursing
Associate of Science - Nursing, RN
Delgado Charity School of Nursing
Certified Case Manager -
Commission For Case Manager Certification
LEADERSHIP SKILLS
- Team Builder
- Mentor/Preceptor
- Cross Functional Collaboration
- Policy and Process Implementation
- Performance/Quality Improvement
- Clinical Advisor
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