Deniece Williams
Little Rock,AR
Summary
My background includes my last position of 6 years, Prior Authorization Nurse for a major insurance company,.with cross training in the role of case management/concurrent nurse to assist when help was needed/required. InterQual, excel, spreadsheets, Microsoft documents -Microsoft word, Electronic health records, data collection, Milliman, Epic, Cerna some of other experience. IRR testing completed 2023 in Procedures, DME, Home Health, and Chiropractic/Rehabilitation. Other specialty areas: Nurse Management, Case Management, Outpatient Surgery, including pre testing, pre operative circulating and post operative, Medical/Surgical, Cardiac, Dialysis, Oncology and Clinical Decision Unit all in a hospital setting. Work history includes working two jobs during same time frame.
I take pride in my work, with strong work ethics, good communication skills, any role while maintaining knowledge of policies, authorization guidelines and continuing changes, as evidenced by including but not limited to: NCQA auditing monthly, IRR testing annually. 1:1 monthly to quarterly with upper management. Accuracy, Efficiency, Effectiveness, Critical Thinking, while strengthening productivity. I believe in teamwork, in any role, with other ancillary departments, that make everything operational In the interests of members/patients and the company. Versatility, able to embrace and adapt to ongoing changes is of upmost importance being independent is mandatory, as well as being a follower, and leader, utilizing those roles when needed, good communication skills, That’s Teamwork. No matter how busy you are, if everyone have the same goals in mind while following guidelines and policies looking out for best practices for members/patients and company. This makes for a productive company. Unity. If I had to list a weakness I would say questionably over focusing on details. I can bring hard work, reliability, dependability, trust, continuity, to any company who will allow me the opportunity to utilize my skills
To add a strength, highly organized, proactive and punctual with team.
Motivated professional offering Bachelor of Science degree in Nursing, interpersonal and multitasking abilities.
Overview
29
29
years of professional experience
Work History
Prior Authorization Nurse/RN Case Manager
Centene
Little Rock , AR
10.2017 - 12.2023
- Reviewed patient medical records to determine if requested services are medically necessary and appropriate for the diagnosis.
- Maintained accurate documentation of all prior authorization activities in accordance with established policies and procedures.
- Provided guidance and support to staff members on prior authorization processes.
- Researched complex cases that require additional information before determining approval and denial status.
- Analyzed clinical data submitted by physician offices in order to approve or deny prior authorization requests.
- Interpreted benefit plans, medical necessity criteria, policy language, and state regulations for proper utilization of services covered under a health plan.
- Assessed the appropriateness of requesting provider's treatment plans based on clinical review criteria set forth by the payer or regulatory bodies.
- Collaborated with physicians' offices regarding pending authorizations and communicated any changes in requirements due to new regulations or policies.
- Developed strategies aimed at improving efficiency within the prior authorization process while maintaining high standards of accuracy and compliance.
- Adhered strictly to HIPAA regulations pertaining to protected health information when handling confidential documents related to patient care.
- Maintained strict patient data procedures to comply with HIPAA laws and prevent information breaches.
- Interpreted and evaluated diagnostic tests to identify and assess patient's condition.
Registered Nurse
Baptist Medical Center
Little Rock, AR
01.2004 - 08.2016
- Performed triage assessments of walk-in patients in a clinic setting.
- Administered medications and treatments according to physician orders.
- Monitored vital signs, administered injections, and provided assistance with medical procedures.
- Documented patient progress notes accurately and efficiently in the electronic medical record system.
- Collaborated with physicians, nurses, therapists, social workers and other healthcare professionals to develop individualized treatment plans for each patient.
- Instructed patients on proper self-care techniques at home following discharge from the hospital.
- Participated in multidisciplinary team meetings to discuss patient care plans.
- Ensured compliance with standards of professional practice as well as state and federal regulations related to health care delivery services.
- Demonstrated knowledge of current trends in nursing practices by attending continuing education classes or seminars.
- Actively participated in quality improvement initiatives within the department.
- Utilized critical thinking skills to assess clinical situations quickly and accurately.
- Maintained a safe environment for all patients by adhering to infection control policies and procedures.
- Provided emotional support and comfort to families during difficult times.
- Counseled patients regarding medication side effects or lifestyle changes necessary for improved health outcomes.
- Assisted physicians during examinations or surgical procedures.
- Developed educational materials for use in teaching sessions with patients or their families.
- Coordinated discharge planning activities including arranging follow up appointments or referrals for additional services.
- Evaluated effectiveness of interventions through ongoing assessment of patient responses.
- Administered medications and treatments, monitoring patients for reactions and side effects.
- Adhered to infection control procedures to facilitate safe, clean patient environment.
- Evaluated patients, recognized and addressed complications and coordinated treatment with other members of critical care team.
- Maintained thorough, accurate and confidential documentation in electronic medical records.
- Acted as patient advocate and implemented total patient care through team nursing process.
- Recorded patient condition, vital signs, recovery progress and medication side effects.
- Monitored and managed various treatment and care interventions.
- Advocated for patients by supporting and respecting basic rights, values and beliefs.
- Administered medications, tracked dosages and documented patient conditions.
- Trained and mentored new RNs on best practices, hospital policies and standards of care.
- Updated charts throughout shifts with current, accurate information to maintain strict recordkeeping standards.
- Provided patient and family health education focusing on self-management, prevention and wellness.
- Assessed and prepared patients for procedures, performing initial and ongoing patient assessments.
- Collected lab specimens, ordering and interpreting diagnostic tests and lab results.
- Maintained personal and team compliance with medication administration standards and patient care best practices.
- Oversaw patient admission and discharge processes to coordinate related paperwork.
- Created, implemented and evaluated patient care plans with medical team.
- Counseled patients and caregivers, providing emotional, psychological and spiritual support.
- Collaborated with doctors to plan post-treatment home care and prevent return hospitalization.
- Conducted intake assessments with patients and relatives to gather case history.
- Monitored patients after surgery, answered questions and provided home care strategies.
- Responded to emergency situations with speed, expertise and level-headed approaches to provide optimal care, support and life-saving interventions.
- Administered oral, IV and intra-muscular medications and monitored patient reactions.
- Helped patients and families feel comfortable during challenging and stressful situations, promoting recovery and reducing compliance issues.
- Assessed patient conditions, monitored behaviors and updated supervising physicians with observations and concerns.
- Observed strict safety measures, including checking medication dosages before administration to patients.
- Advocated for patient needs with interdisciplinary team and implemented outlined treatment plans.
- Coordinated with healthcare team to establish, enact and evaluate patient care plans.
- Maintained strict patient data procedures to comply with HIPAA laws and prevent information breaches.
- Delivered information regarding care and medications to patients and caregivers in comprehendible terminology.
- Utilized computerized Resource and Patient Management System (RPMS) and Electronic Health Record (EHR) system.
- Modified patient treatment plans as indicated by patients' responses and conditions.
- Prepared medical equipment and tools to aid physician during examination and treatment of patients.
- Interpreted and evaluated diagnostic tests to identify and assess patient's condition.
Registered Nurse
CHI St Vincent
Little Rock, AR
LPN Office Nurse/Triage Nurse
Little Rock Cardiology Clinic/Arkansas Heart Clin
Little Rock, AR
07.1994 - 05.2002
Education
Bachelor of Science - Nursing
University Arkansas
Little Rock, AR05.2013
Diplomacy - Nursing
Baptist Health Schools Little Rock
Little Rock, AR01.2004
Skills
- Chronic Disease knowledge and management
- Detailed Documentation
- Case Management
- Critical Thinking
- Patient Care Assessment
- Diabetes Management
- Compassionate and Caring
- Good Decision-Making
- Nursing
- Strong Clinical Judgment
- Diagnostic Software
- Diagnostic Tools Experience
- Excel, InterQual, Milliman, Cerna, Spreadsheet, Epic
- Electronic Health Records
- Microsoft Office Microsoft Word
- Healthcare Program Planning
- Motivation
- Patient Care Oversight
- ICD-10
- Attention to Detail
- Needs Assessment
- Medical Record-keeping
Timeline
Prior Authorization Nurse/RN Case Manager
Centene
10.2017 - 12.2023
Registered Nurse
Baptist Medical Center
01.2004 - 08.2016
LPN Office Nurse/Triage Nurse
Little Rock Cardiology Clinic/Arkansas Heart Clin
07.1994 - 05.2002
Registered Nurse
CHI St Vincent
Bachelor of Science - Nursing
University Arkansas
Diplomacy - Nursing
Baptist Health Schools Little Rock