Gabrianne Bain
Summary
Registered Nurse with 12 years of experience including leadership roles in bedside and utilization management.
Overview
12
12
years of professional experience
1
1
Certification
Work History
Nurse Medical Management II (US) • Clinical Coding and Claims Med Mgmt Clinician Sr
Elevance Health
11.2022 - Current
- Responsible to collaborate with healthcare providers and members to promote quality member outcomes, to optimize member benefits, and to promote effective use of resources for more complex medical issues.
- Reconsideration and Appeal reviews of various types of claims inpatient and outpatient for medical necessity and coding determinations
- Systems and applications experience: Wellpoint Group Systems (WGS), Supression/Mainframe, Member 360, Sharepoint, Anthem Care Management Platform (ACMP), Outlook Word, Excel, Powerpoint, Office of Medical & Technology Assessment (OMPTA), Citrix, Carelon, MCG, EPP / EMR
- Ensures medically appropriate, high quality, cost effective care through assessing the medical necessity of inpatient admissions, outpatient services, focused surgical and diagnostic procedures, out of network services, and appropriateness of treatment setting by utilizing the applicable medical policy and industry standards, accurately interpreting benefits and managed care products, and steering members to appropriate providers, programs or community resources.
- Works with medical directors in interpreting appropriateness of care and accurate claims payment.
- May also manage appeals for services denied.
- Knowledge of medical management process and ability to interpret and apply member contracts, member benefits, and managed care products
- ICU, CCU or Unit experience
- Conducts precertification, continued stay review, care coordination, or discharge planning for appropriateness of treatment setting reviews to ensure compliance with applicable criteria, medical policy, and member eligibility, benefits, and contracts.
- Consults with clinical reviewers and/or medical directors to ensure medically appropriate, high quality, cost effective care throughout the medical management process. Collaborates with providers to assess member’s needs for early identification of and proactive planning for discharge planning.
- Facilitates member care transition through the healthcare continuum and refers treatment plans/plan of care to clinical reviewers as required and does not issue non-certifications.
- Facilitates accreditation by knowing, understanding, correctly interpreting, and accurately applying accrediting and regulatory requirements and standards.
- Serves as resource to lower-leveled nurses and may participate in or lead intradepartmental teams, projects and initiatives.
RN / RN Relief Charge
Baptist Health Louisville
07.2018 - 02.2023
- Cared for ICU, CCU, ED, All hospital inpatients, Urgent and Emergent patients
- IVs on critical patients: mostly 16g – 18g and occasionally 14g
- Titrated infusions
- Administered blood and blood products
- Administered sedative medications
- Assisted surgeons and anesthesia with inserting Arterial Lines, Epidurals, Heart Lines, Swan Catheters and Cordis’
- Maintained Arterial Lines, Epidurals, Heart Lines, Swan Catheters and Cordis’
- Assisted with performing Orthopedic Nerve Blocks
- Head to Toe Assessment
- Venipuncture
- Phase II Recovery and D/C pts to home
MA/LPN/RN
Baptist Health, Urgent Care
03.2013 - 12.2019
- Venipuncture / IV Skills
- Triaging
- Drug Testing – DOT , Non-DOT
- Wound Dressings and Treatment
- In-house testing such as strep, flu, mono
- Injections – IM, ID, Subcutaneous.
- Urinalysis
- EKG performance and analysis.
- Ortho-Glass and Splinting Application
- Assisting with lacerations / suturing
- Optical Care
- Workers Comp Claims – Treatment and Physicals
Education
BSN - undefined
WGU
07.2020
RN - ADN - undefined
JCTC
06.2016
LPN - undefined
JCTC
06.2013
CNA - undefined
Shelby County Highschool Vocational Center
06.2009
Skills
- Medication administration
- Medication and IV administration
- Patient care
- Direct patient care
- Patient assessment
- Clinical documentation
- Patient education
- Infection control
- Clinical judgment
- Patient management
- Compassionate care
- Healthcare ethics
- Licensed RN
- Wound management
- Surgical care
- Care coordination
- Critical care nursing
- Nursing staff leadership
- Seizure management
- Tracheostomy care
- Unit administration
- Triage assessment
- Blood transfusion administration
- Nursing assessments
- Phlebotomy techniques
- Medication reconciliation
- Patient advocacy
- Inpatient care
- Outpatient care
- Discharge planning
- Telemetry and advanced cardiac care
- Direct nursing care
- Patient safety monitoring
- Medical chart management
- Patient care and education
- Electronic health records management
- NG tube insertion
- Nursing staff development
- Advanced cardiac life support
- Catheter maintenance
- Utilization review
- Interdisciplinary collaboration
- Medical necessity evaluation
- HIPAA compliance
- Insurance verification
- Records analysis
- Documentation and reporting
- Interpersonal and written communication
- Utilization management
- Medical coding
- Medicaid
- Needs assessment
- Patient transfers and transitions
- Compliance procedures
- Teamwork
- Time management
- Attention to detail
- Problem-solving abilities
- Multitasking
- Strong clinical judgment
- Critical thinking
- CPR certification
- Adaptability and flexibility
- Creative problem solving
- Decision-making
- Patient and family advocacy
Certification
- Current CNA, American Red Cross
- Current ACLS, American Red Cross
Timeline
Nurse Medical Management II (US) • Clinical Coding and Claims Med Mgmt Clinician Sr
Elevance Health
11.2022 - Current
RN / RN Relief Charge
Baptist Health Louisville
07.2018 - 02.2023
MA/LPN/RN
Baptist Health, Urgent Care
03.2013 - 12.2019
BSN - undefined
WGU
RN - ADN - undefined
JCTC
LPN - undefined
JCTC
CNA - undefined
Shelby County Highschool Vocational Center