Chelsea Seamans-Williams
RN, CCM
Mechanicville,NY
Summary
Dedicated and compassionate Registered Nurse (RN) with progressive career history in direct patient care, triage and care coordination in fast-paced environment. Proven to remain calm under pressure and skillfully handle difficult patients and high-stress situations. Consistently developing strong relationships with patients and families through empathetic communication, respectful attitude and excellent customer service.
Overview
13
13
years of professional experience
3
3
Certifications
Work History
Clinical Appeals Specialist
Centene-Telecommute
01.2022 - Current
- Review clinical information for all appeals utilizing nationally recognized criteria to determine medical necessity of services requested
- Prepare reviews for cases that did not meet criteria
- Prepare response letters for member and provider and ensure letters are compliant with state and NCQA standards
- Coordinate with Medical Directors to clarify medical determinations/clinical rationale
- Also performs Quality Care Reviews
- Investigates complaints to determine if there was a potential quality of care issue that took place
- Request and review medical records and make appropriate referrals including peer reviews, patient safety work groups and credentialing committee
- Provide written communications to facilities with findings and recommendations.
Care Manager
Landmark Health
Latham
07.2019 - 06.2021
- Engage patient and families to collaborate and discuss plan of care and ongoing management of patient's condition
- Education, provide guidance, and support using nursing assessments and medical records review
- Help guide treatment and care decisions working as part of an interdisciplinary team
- Identifies needed services and vendors to help patients navigate their care
- Monitors patient progress and acts as advocate and liaison between all providers
- Coordinated with providers to identify and assist with CMS gap closure.
MLTC Telephonic Case Manager
UHC-Telecommute
07.2018 - 07.2019
- Review and evaluate UAS assessment
- Outreach members to assess health status monthly, and as needed
- Identify gaps in treatment plans
- Implements care plan
- Provide education about disease process and healthy lifestyle changes
- Assist with coordination of care and authorizations for services including home health, meal delivery, and DME needs
- Assist to facilitate transition of care when members come home from hospitalizations.
Telephonic Case Manager
Aetna Insurance
Albany
01.2016 - 01.2018
- Establish trusting relationship with members to assist them in meeting their individual health needs
- Use of motivation interviewing to help set health goals and plans of care
- Communicates with providers to find available resources within the member's benefit design
- Facilitate optimal, cost-effective outcomes using clinical judgment to incorporate strategies designed to reduce risk factors.
Case Manager
Community Health Eddy Visiting Nurses
Troy
01.2014 - 01.2017
- Provide care to acute and chronically ill patients in the home setting
- Perform OASIS assessments
- Provide teaching, medication management, wound care, and discharge planning within Medicare/Medicaid and group insurance guidelines
- Collaborated in interdisciplinary meetings to assist with the needs of chronically ill patients
- Advocate for patients as needed.
Registered Nurse
Albany Medical Center
Albany
01.2013 - 01.2015
- Using nursing process, provided care to pre and post op patients
- Performed skilled nursing assessments, administered medications, IV fluids, and Blood Products, monitored labs and patient recovery, reporting to findings to M.D
- When appropriate
- Completed 1 year nurse residency program, including an Evidence Based Research project that was presented to Administration.
Technical Care Associate
St. Peter's Hospital
Albany
01.2011 - 01.2012
- Obtained and recorded patient vital signs
- Assisted patients with daily grooming, transferring and ambulation
- Performed EKG's
- Monitored Telemetry for up to 30 patients, including measuring and interpreting of strips
- Reported findings to RN's when appropriate.
Education
AAS in Nursing - Nursing
Skills
Proficient in Microsoft Excel, Word, and OfficeActive LearnerAdaptableRelationship BuildingMotivational Interviewing
Certification
RN, 05/2023, NY
Vaccination Status - Moderna
2
Timeline
Clinical Appeals Specialist - Centene-Telecommute
01.2022 - Current
Care Manager - Landmark Health
07.2019 - 06.2021
MLTC Telephonic Case Manager - UHC-Telecommute
07.2018 - 07.2019
Telephonic Case Manager - Aetna Insurance
01.2016 - 01.2018
Case Manager - Community Health Eddy Visiting Nurses
01.2014 - 01.2017
Registered Nurse - Albany Medical Center
01.2013 - 01.2015
Technical Care Associate - St. Peter's Hospital
01.2011 - 01.2012
Maria College - AAS in Nursing, Nursing