Cindy R. Bolen
Dora,Alabama
Summary
Registered Nurse with 15 years in utilization review and case management, specializing in Medicare Advantage. Expertise in analyzing medical records for compliance with CMS guidelines and efficiently managing high-volume workloads while ensuring accuracy in coverage determinations. Active multi-state RN license facilitates care coordination across state lines.
Overview
26
26
years of professional experience
1
1
Certification
Work History
Utilization Review Coordinator/Medical Review Nurse
Blue Cross Blue Shield of Alabama
Birmingham, Alabama
01.2019 - Current
- Analyze complex medical records using CMS guidelines and internal policies to make accurate coverage determinations
- Perform prospective, concurrent, retrospective, and appeal reviews to determine medical necessity and coverage, focusing on Medicare Advantage cases in compliance with CMS regulations
- Collaborate with providers and internal teams to obtain clinical information and support timely decisions
- Manage a high-volume caseload while maintaining strong accuracy and meeting productivity expectations
- Ensure adherence to regulatory standards and member benefit plans
- Consistently meet or exceed quality assurance and productivity benchmarks
Care Coordinator / Utilization Review Coordinator
Blue Cross Blue Shield of Alabama
Birmingham, Alabama
01.2013 - 01.2019
- Develop and implement individualized care plans to improve outcomes and close gaps in care
- Identify barriers to care and implement solutions to improve patient outcomes
- Conducted member outreach and completed comprehensive care assessments to identify individual needs and enhance care coordination
- Coordinate with providers for discharge planning and ongoing care needs
- Educated members on disease management, medications, and available benefits to empower informed health decisions
Precertification Nurse/Coordinator
Athena Health
Birmingham, Alabama
01.2011 - 01.2013
- Coordinated communication between payers, providers, and scheduling teams to secure timely approval outcomes
- Executed insurance precertifications through payer systems and online portals, facilitating timely patient access to services
- Verified eligibility, benefits, and coverage details to support accurate care coordination
- Maintained high productivity and audit accuracy standards
Critical Care Registered Nurse
Baptist Medical Center Princeton
Birmingham, Alabama
01.2009 - 01.2011
- Monitored patient status, implementing critical care interventions to stabilize conditions
- Developed and executed comprehensive patient care plans in high-acuity environment, ensuring optimal recovery
- Provided care for cardiac ICU patients, including post-operative open-heart cases
Pacemaker/Coumadin Technician
Cardiology, P.C.
Birmingham, Alabama
01.2000 - 01.2008
- Monitored cardiac rhythms and anticoagulation therapy results to ensure patient safety and effective treatment
- Communicated findings to physicians and coordinated patient care to enhance treatment decisions
- Educated patients on treatment plans, medications, and monitoring procedures to promote adherence and understanding
Education
Bachelors of Science - Nursing
University of Alabama
Tuscaloosa, Alabama05-2017
Associates Degree - Nursing
Jefferson State Community College
Birmingham, Alabama12-2008
Skills
- Utilization Review
- Medical Necessity Determination
- InterQual Criteria
- Clinical Guidelines
- CMS Guidelines
- Medicare Advantage Policies
- Case Management
- Care Coordination
- Medical Record Review
- Documentation Analysis
- Provider Communication
- Healthcare Systems
Certification
- Registered Nurse, Alabama, Active
- Multi-state RN license (Compact), Active
References
Available Upon Request
Timeline
Utilization Review Coordinator/Medical Review Nurse
Blue Cross Blue Shield of Alabama
01.2019 - Current
Care Coordinator / Utilization Review Coordinator
Blue Cross Blue Shield of Alabama
01.2013 - 01.2019
Precertification Nurse/Coordinator
Athena Health
01.2011 - 01.2013
Critical Care Registered Nurse
Baptist Medical Center Princeton
01.2009 - 01.2011
Pacemaker/Coumadin Technician
Cardiology, P.C.
01.2000 - 01.2008
Bachelors of Science - Nursing
University of Alabama
Associates Degree - Nursing
Jefferson State Community College