Cicely Denmon
Middleburg,FL
Summary
Proven problem-solving, analytical, and creative thinking skills. Proficient with HCPCS, ICD-9, CM, and Medical Terminology. Profound ability to plan, manage and organize. Well-qualified Nurse Consultant bringing 10 years of medical care and case review experience. Critically evaluates documents and develops summaries.
Overview
10
10
years of professional experience
Work History
Nurse Consultant
Toney Healthcare
11.2021 - Current
- Gathering clinical information and applying appropriate clinical criteria/guideline, policy, procedure, and clinical judgment to render coverage determination/recommendation along continuum of care
- Communicating with providers and other parties to facilitate care/treatment
- Identifying members for referral opportunities to integrate with other products, services and/or programs
- Identifying opportunities to promote quality effectiveness of Healthcare Services and benefit utilization
- Consulting and lending expertise to other internal and external constituents in coordination and administration of utilization/benefit management function
- Enhanced efficiency of healthcare teams through provision of expert guidance on clinical practices and protocols.
- Collaborated with interdisciplinary teams to design evidence-based interventions aimed at improving patient health and wellness.
- Influenced positive changes in organizational policies by participating in key decision-making committees focused on patient safety and quality improvement initiatives.
- Managed approximately 30 cases involving multiple healthcare providers, ensuring timely coordination of services for optimal patient outcomes.
- Reviewed medical records and summarized care.
- Followed all personal and health data procedures to effectively comply with HIPAA laws and prevent information breaches.
- Investigated and resolved issues affecting hospital operations and patient care.
- Improved member satisfaction by efficiently managing and resolving appeals and grievances cases.
- Enhanced internal processes for handling complaints by developing standardized guidelines and documentation templates.
- Expedited resolution times by proactively communicating with members, providers, and other stakeholders throughout grievance process.
- Ensured timely submission of required reports to regulatory agencies by diligently monitoring deadlines and maintaining accurate records.
- Reduced turnaround times for case resolutions by effectively prioritizing workload based on urgency levels designated by regulatory standards.
- Demonstrated high-level attention to detail when reviewing medical records, provider contracts, and other relevant documents during case assessments.
- Provided exceptional customer service when interacting with individuals involved in each appeal or grievance situation, demonstrating empathy and professionalism at all times.
- Processed and finalized appeals and grievances within agreed-upon turnaround time.
- Submitted verbal and written notification to members and providers.
Nurse Auditor
David James LLC
08.2022 - 07.2023
- Auditing charts of Part C Organization Determinations, Appeals and Grievances (ODAG), Special Needs Plan Model of Care (SNP MOC), and/or Programs of All-Inclusive Care for Elderly (PACE)
- Reviewing policies and procedures, internal controls, and claims/medical records to determine organization's compliance with Medicare rules and regulations.
- Streamlined audit processes for increased efficiency, utilizing electronic health record systems and data analysis tools.
- Collaborated with interdisciplinary teams to address issues discovered during audits, contributing to improved patient care outcomes.
- Reviewed coding practices for consistency and accuracy, promoting appropriate reimbursement levels for services provided.
- Assisted in development of policies and procedures related to nursing audits, ensuring organizational alignment with industry standards.
- Maintained up-to-date knowledge of regulatory changes impacting nursing profession, integrating these updates into ongoing auditing activities accordingly.
- Participated in continuing education opportunities focused on advancements in healthcare auditing techniques and best practices within nursing.
- Assisted in preparation of 4 medical reports for external parties.
- Identified new methods to optimize medical records management.
UM Nurse Consultant
Aetna Better Health/AHH
05.2014 - 11.2020
- Utilizing clinical experience and skills in to facilitate appropriate healthcare services/benefits for members for approximately 35 members per day
- Gathering clinical information and applying appropriate criteria/guideline, policy, procedure, and clinical judgment to render coverage determination/recommendation
- Communicating with providers and other parties to facilitate care/treatment
- Identifying members for referral opportunities to integrate with other products, services and/or programs
- Consulting and lending expertise to other internal and external constituents in coordination and administration of utilization/benefit management function
- Improved patient care by developing and implementing customized nursing plans for diverse medical conditions.
- Enhanced efficiency of healthcare teams through provision of expert guidance on clinical practices and protocols.
- Assessing patient outcomes and creating patient-centered care plans
- Promoting effective utilization of available resources for optimal member functioning, and cost-effective outcomes
- Educating patient/family with focus on self-management, prevention, and wellness, based on patient's individual goals.
- Assisted in reduction of hospital readmission rates by providing comprehensive patient education and follow-up support.
Education
Master of Science /Executive Nursing -
Chamberlain College of Nursing
Illinois06.2014
Bachelor of Science in Nursing -
Chamberlain College of Nursing
Illinois03.2010
Associate of Applied Science -
Columbus State Community College
Ohio12.2008
Skills
- Data Analysis
- Quality Improvement
- Medical Documentation
- Organizing medical records
- Analyzing documentation
- Records Review
- Case Management
- Attention to Detail
- Teamwork and Collaboration
- Effective Communication
- Professionalism
- Organizational Skills
Licenses Certifications Memberships
- Current Florida Registered Nurse (RN) Compact License
- Sigma Theta Tau International Honor Society of Nursing
Timeline
Nurse Auditor
David James LLC
08.2022 - 07.2023
Nurse Consultant
Toney Healthcare
11.2021 - Current
UM Nurse Consultant
Aetna Better Health/AHH
05.2014 - 11.2020
Master of Science /Executive Nursing -
Chamberlain College of Nursing
Bachelor of Science in Nursing -
Chamberlain College of Nursing
Associate of Applied Science -
Columbus State Community College
Similar Profiles
LOREN TONEYLOREN TONEY
Photographer at Loren Toney PhotographyPhotographer at Loren Toney Photography
Victoria WardVictoria Ward
Cashier at Toney Ace HardwareCashier at Toney Ace Hardware
Tiana BourneTiana Bourne
Resident Teacher at Toney Elementary SchoolResident Teacher at Toney Elementary School
Christina GrahamChristina Graham
CTSS / DQS & AGM - Senior Support Specialist III at BCD TravelCTSS / DQS & AGM - Senior Support Specialist III at BCD Travel
Jason MorinitiJason Moriniti
Aviation Electrician at Northrop GrummanAviation Electrician at Northrop Grumman