Helen Edwards
Suffolk,Virginia
Summary
Goal is to gain employment working as a Licensed Practical Nurse. Four years of working remotely I'm organized and dependable candidate successful at managing multiple priorities with a positive attitude. Willingness to take on added responsibilities to meet team goals. Seeking and maintaining a full-time position that offers professional challenges utilizing interpersonal skills, excellent time management and problem-solving skills.
Overview
18
18
years of professional experience
1
1
Certification
Work History
Care Coordinator
Carelon Medical Benefit management, Stars Program
07.2023 - Current
- I am responsible for ensuring patients are able to do what is required after being discharged from acute care facility or being seen in emergency department.
- This entails making sure that follow up appointments are made to PCPs or specialty providers after discharges.
- Assessing if any needs might require additional assistance with getting their medications, transportation to appointments, or assistance with getting their groceries.
- Managed patient caseloads effectively, ensuring timely follow-up and appropriate interventions.
- Maintained accurate and up-to-date documentation of patient records in accordance with HIPAA regulations.
- Educated patients on self-care strategies, promoting independence and empowering them to manage their health conditions.
- Assessed patient needs and connected them with appropriate resources to ensure optimal health outcomes.
Licensed Utilization Management II
Elevance Health
04.2020 - 07.2023
- Worked in Medicare GBD
- Reviewed requests submitted by Providers, and DME providers for prior authorization for outpatient, inpatient, diagnostic testing, and DME
- Determined if member had benefit, reviewing clinical information provided by providers that met CMS guidelines InterQual and MCG
- Position also entails that I prepare and submit denials and clinical documentation that does not meet criteria to Medical Directors.
- Self-motivated, with a strong sense of personal responsibility.
- Worked effectively in fast-paced environments.
- Skilled at working independently and collaboratively in a team environment.
- Proven ability to learn quickly and adapt to new situations.
- Excellent communication skills, both verbal and written.
- Worked well in team setting, providing support and guidance.
- Demonstrated respect, friendliness and willingness to help wherever needed.
- Passionate about learning and committed to continual improvement.
- Worked flexible hours across night, weekend, and holiday shifts.
- Managed time efficiently in order to complete all tasks within deadlines.
- Organized and detail-oriented with strong work ethic.
- Paid attention to detail while completing assignments.
- Used critical thinking to break down problems, evaluate solutions and make decisions.
- Developed and maintained courteous and effective working relationships.
- Managed approximately 30 incoming calls, emails and faxes per day from Providers.
LPN (Licensed Practical Nurse)
First Choice Nurses
04.2018 - 02.2020
- Contracted to work for different LTC facilities as LPN Charge Nurse
- Experience in skill care nursing, trach and vent patients, wound care, IV therapy and head to toe assessments
- Also experience with point click care, Interactant and Epic
- Worked as wound care nurse and Charge nurse.
LPN Charge Nurse
Bayside Health And Rehabilitation Center
09.2017 - 04.2018
- Specialized in Skilled nursing: Monitoring vital signs, passing meds, IV therapy, pre-admission, assisting with ADLS, Assessments, injections, ppd monitoring, glucose checks.
- Assessed patient progress regularly, adjusting treatment plans as needed to maximize results.
- Approved and monitored clinic expenses relating to supplies, equipment, and staffing.
- Identified barriers to treatment and provided clinical education to meet patient needs.
- Communicated with patients, ensuring that medical information was kept private.
- Ordered all pharmacy supplies and kept check on inventory levels.
- Achieved successful unit leadership by providing quality nursing care to 1 to 20 patients per day in 60-bed unit.
Authorization Coordinator Nurse
Optima Health Insurance
01.2015 - 08.2017
- Making sure clinical documentation meets medical necessity to be authorized for outpatient surgeries, MRIs and CTs
- Collaborated with multidisciplinary teams to ensure timely submission of documentation required for insurance approval.
- Improved patient care by efficiently coordinating authorizations for medical procedures and treatment plans.
- Facilitated timely renewals of ongoing authorizations by closely monitoring expiration dates and initiating renewal processes proactively.
- Submitted for prior authorization with required documentation to appropriate funding source.
- Reviewed documentation for accuracy and assessment of necessity.
- Managed approximately 30 incoming calls, emails and faxes per day from customers
License Practical Nurse
Sentara Virginia Beach General Observation Unit
02.2008 - 08.2017
- Specialized in med/sur nursing
- Giving proper patient education on their conditions
- Vital sign monitoring, passing meds, IV therapy, computer charting maintaining proper Hippa protocols, and DNV protocols
- Giving effective handoffs, to oncoming nurse
- Admissions, preop and postop care
- Skilled in taking care of postop urology, plastic surgery, general surgery, and orthopedic surgery
- Also a resource nurse in Recovery, and OSPMU.
Agency Nurse
Maxim Healthcare Services
08.2012 - 09.2013
- Specialized in med/sur nursing
- Giving proper patient education on their conditions, vital sign monitoring, passing meds, IV therapy, computer charting maintaining proper Hippa protocols, and Joint Commission protocols and giving effective handoffs, to the oncoming nurse.
License Practical Nurse
Sentara Norfolk General 4K Med/Surg
01.2006 - 02.2008
- Specialized in med/sur nursing
- Giving proper patient education on their conditions
- Vital sign monitoring, passing meds, IV therapy, computer charting maintaining proper Hippa protocols, and Joint Commission protocols
- Giving effective handoffs, to oncoming nurse
- Admissions, preop and postop care
- Skilled in taking care of postop urology, plastic surgery, general surgery, and orthopedic surgery.
Education
BLS certified
Licensed Practical Nurse -
Sentara School of Health Professions
01.2005
Nursing Care Partner -
Sentara School of Health Professions
01.1998
Skills
- Licensed Practical Nurse highly skilled in utilization review with over 3 years of experience in utilization review management in Medicare for Health Plan and 2 years' experience in commercial health plan I am able to use critical thinking skills, for case reviews, reviewing provider's requests for outpatient and inpatient procedures, medical transportation durable medical equipment that are required by members or patients being discharged from acute care facility, or SNF by using CMS and MCG guidelines I have 18 years of experience working in acute care and LTC setting Current work experience working as Clinical Care Coordinator for Medicare Stars program Experienced in computer charting such as Epic, PCC, and Interactant Proficient with Microsoft Outlook, Teams Word, and excel spreadsheets
- Documentation
- Patient Education
- Organizational Skills
- Medical terminology understanding
- Documentation proficiency
- Policy Adherence
- HIPAA Guidelines
- Critical Thinking
- Case Management
Certification
- Connecticut
- New York
- California
- Virginia
References
References upon request
Timeline
Care Coordinator
Carelon Medical Benefit management, Stars Program
07.2023 - Current
Licensed Utilization Management II
Elevance Health
04.2020 - 07.2023
LPN (Licensed Practical Nurse)
First Choice Nurses
04.2018 - 02.2020
LPN Charge Nurse
Bayside Health And Rehabilitation Center
09.2017 - 04.2018
Authorization Coordinator Nurse
Optima Health Insurance
01.2015 - 08.2017
Agency Nurse
Maxim Healthcare Services
08.2012 - 09.2013
License Practical Nurse
Sentara Virginia Beach General Observation Unit
02.2008 - 08.2017
License Practical Nurse
Sentara Norfolk General 4K Med/Surg
01.2006 - 02.2008
BLS certified
Licensed Practical Nurse -
Sentara School of Health Professions
Nursing Care Partner -
Sentara School of Health Professions
- Connecticut
- New York
- California
- Virginia
Similar Profiles
Gabrielle RoblesGabrielle Robles
Referral Specialist II at Carelon Medical Benefits ManagementReferral Specialist II at Carelon Medical Benefits Management
Maria RangelMaria Rangel
Referral Specialist at Carelon Medical Benefits ManagementReferral Specialist at Carelon Medical Benefits Management
MELISSA VILLAMELISSA VILLA
Nurse Reviewer Senior at Carelon Medical Benefits ManagementNurse Reviewer Senior at Carelon Medical Benefits Management