Chinyere Ada Choice
Healthcare. Finance. Accounting
Baltimore,MD
Summary
Experienced registered nurse with additional computer expertise focused on financial management, accounting, and business administration. Prepared by education and experience for position in Healthcare IT or as Data Analyst. Knowledge of health care and managed Medicare delivery systems: standards of medical practice; insurance benefits structure and related legal/medical issues; and utilization management and quality improvement process. Direct care experience encompassing acute care, hospital CM, trauma rehabilitation, oncology, palliative care, hospice care, and complex illnesses. Broad understanding of patient care and hospital and clinic administration, combined with comprehensive education and capability in finance and accounting acquire through university education and prior work in accounting and data analysis.
Overview
10
10
years of professional experience
Work History
Inpatient Care Coordinator/Manager
Sinai Hospital of Baltimore
07.2021 - 06.2022
- Discharge planning to lower levels of care accomplished through coordination and communication with the entire health care team, patients, families/friends, and various outside care facilities such as (SAR's, ALF, LTC, Home Care companies, DME companies, Shelters, Substance abuse rehabs, and Charitable organizations).
Inpatient ED Utilization Review Nurse
Ascension Health, Saint Agnes Hospital
Baltimore, MD
03.2020 - 07.2021
- Case Management and ED Utilization RN
- Analyze ED patients to determine the appropriate level of care, and if necessary, advice providers to levels least likely to be denied by insurers
- Write care protocols to be submitted to insurance for reimbursement
- Creates plan for care across the continuum, integrating patient/family preferences and values
- Monitors patient care through assessments, evaluations, and/or patient records
- Advocates for resources and removal of barriers
- Maintains ongoing dialog with supervisor and other health providers to ensure effective implementation of health plan
- Acts as a resource for adequate medical record documentation, appropriateness of services as they relate to diagnoses, and treatment options for post-discharge care.
Continuous Quality Improvement
Corizon Health
04.2019 - 03.2020
- Monitor and evaluate medical care delivery in accordance with policies and procedures thru monthly “Trust and Verify” CQI audits
- Work closely with the Quality Director to ensure appropriate measures for education and performance adjustment are taken to provide the best quality care
- Monitor metrics in quality and patient safety, to provide recommendation for performance improvement initiatives in Nursing and Clinical Operations
- Maintain chronic care data base collaboratively with the AA Scheduler ensuring all chronic care is completed in accordance with PCM policies
- Maintain a professional working relationship with facility staff, unit staff, contracted providers, outside service providers and corporate staff
- Make use of established Corporate and facility policies and procedures in clinical practice
- Must use factual data and sound independent judgment in meeting the responsibilities and performing the duties of a staff nurse
- Monitor nursing services to avoid the inappropriate use and/or duplication of services
- Advises DON and/or H.S.A if these situations arise
- Monitor and recommend methods to improve operational efficiency and cost containment effectiveness
- Staffing Agencies to include (Ranstad, Health Care Support)
HEDIS Data Analyst
United Health Care
11.2016 - 05.2017
- As member of Quality Analyst Team, monitored and supported health plan quality improvement initiatives with particular emphasis on compliance with accreditation requirements
- Collaborated with other critical areas of quality assurance, including national and regulatory teams, CMS/SNP teams, and other related parties
- Assisted with implementation of National HEDIS improvement plan, including data collection and clinical improvements
- Participated in determination of annual HEDIS strategy, and additional clinical improvements
- Collaborated with HEDIS project managers in collecting relevant RFI, ROADMAP, and HOQ information
- Partnered with Regional Quality Team to identify and implement regional and/or state-specific projects to improve HEDIS scores
- Participated in regional quality programs and committees as needed
- Identified opportunities to actively participate in process improvement related to enhanced health plan quality
- Assisted in developing targeted educational reminders for clinical and preventive initiatives.
Inpatient Utilization Review Nurse
Medstar Washington Hospital Center
05.2017 - 04.2018
- Responsible for assuring the receipt of high quality, cost efficient medical outcomes for those enrollees identified as having the need for inpatient and or outpatient precertification or preauthorization
- Used clinical knowledge and nursing experience to review provider requests for inpatient and outpatient services, working closely with members and providers to collect all information necessary to perform a thorough medical necessity review
- When necessary, pend requests for additional information and/or request clarification
- Apply medical health benefit policy and medical management guidelines to authorize services, and appropriately identify and refer requests to the Medical Director when guidelines are not met
- Maintain current knowledge and understanding of the laws, regulations, and policies that pertain to the organizational unit’s business and uses clinical judgment in their application
- Use professional judgment to evaluate the request to ensure that appropriate services are approved and recognize care coordination opportunities and refer those cases as needed
- Establish effective rapport with other employees, professional support service staff, customers, clients, patients, families and physicians
- Use effective relationship management, coordination of services, resource management, education, patient advocacy and related interventions to:
- Promote improved quality of care and/or life
- Promote cost effective medical outcomes
- Prevent hospitalization when possible and appropriate
- Promote decreased length of hospital stays when appropriate
- Provide for continuity of care
- Assure appropriate levels of care are received by patients
- Provide appropriate consultations and referrals to Case Management Personnel
- Provide advice and counsel to precertification staff
- Identify appropriate alternative and non-traditional resources and demonstrate creativity in managing each case to fully utilize all available resources.
Appeals Analyst/Utilization Review RN
Maryland Physicians Care, Aetna MCO
05.2016 - 11.2016
- Research, analyze, evaluate and respond to providers appeals on complex cases
- Conduct, review and summarize medical literature to communicate associated parties regarding medical facts and issues relating to cases or claim payment
- Integrate nursing knowledge with insurance litigation in accordance with state and federal laws
- Conduct clinical review and evaluation of member and provider appeals and grievances using considerable clinical judgment, independent analysis and detailed knowledge of medical policies, clinical guidelines and benefit plans, to determine the appropriateness of care provided
- Review, triage and prioritize cases to meet required turnaround times
- Interact with external partners, including providers, medical groups, and other external vendors to obtain additional information to resolve the member’s case
- Summarize cases including articulation of member’s perception, initial denial determination and notification, analysis of medical records, and appropriate application of all applicable policies, guidelines, benefit plan and laws, rules and regulations
- Perform data entry and data management for all appeals and grievances in the designated information systems and any other appropriate tracking systems.
Registered Nurse
Saint Agnes Hospital
02.2008 - 04.2009
- Acute care – bedside – Medsurg.
Registered Nurse
Howard County General Hospital
07.2003 - 10.2006
- Acute care – bedside – Medsurg
Education
MSN/MBA - undefined
Grand Canyon University
Skills
Utilization/Appeals Management:Broad Computer Expertiseundefined
Work Availability
monday
tuesday
wednesday
thursday
friday
saturday
sunday
morning
afternoon
evening
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Quote
Success is not final; failure is not fatal: It is the courage to continue that counts.
Winston S. Churchill
Timeline
Inpatient Care Coordinator/Manager
Sinai Hospital of Baltimore
07.2021 - 06.2022
Inpatient ED Utilization Review Nurse
Ascension Health, Saint Agnes Hospital
03.2020 - 07.2021
Continuous Quality Improvement
Corizon Health
04.2019 - 03.2020
Inpatient Utilization Review Nurse
Medstar Washington Hospital Center
05.2017 - 04.2018
HEDIS Data Analyst
United Health Care
11.2016 - 05.2017
Appeals Analyst/Utilization Review RN
Maryland Physicians Care, Aetna MCO
05.2016 - 11.2016
Registered Nurse
Saint Agnes Hospital
02.2008 - 04.2009
Registered Nurse
Howard County General Hospital
07.2003 - 10.2006
MSN/MBA - undefined
Grand Canyon University
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