James Johnson, RN, BSN
Graham,NC
Summary
Dedicated and compassionate healthcare professional (RN) with over 18 years of payer-side experience in utilization management, clinical documentation improvement (CDI), and denial prevention. Experienced in leading teams and managing operations across pre-service and post-service reviews, with a focus on quality, compliance, and efficiency. Skilled at turning clinical insights into streamlined, data-driven processes that improve care quality and control costs. Recognized for developing and mentoring multidisciplinary teams, building collaboration between clinical, operational, and technical staff, and driving consistent, measurable results. Well-versed in payer regulations and emerging healthcare standards, with a proven ability to strengthen utilization review programs and adapt to evolving organizational needs. Recognized for strong communication, reliable leadership, and a thoughtful, solutions-focused approach to problem-solving and continuous improvement.
Overview
22
22
years of professional experience
Work History
Supervisor, Clinical Teams
Blue Cross Blue Shield of North Carolina
07.2023 - Current
- Manage daily prior review and post-service review processes for inpatient and outpatient services across commercial, Medicare, and state lines of business, ensuring reviews meet CMS, NCQA, and URAC quality and compliance standards.
- Supervise and coach a multidisciplinary team of clinical and administrative staff to meet performance goals, turnaround standards, and quality benchmarks.
- Partner with Medical Directors and Clinical Reviewers to resolve complex medical necessity determinations and ensure consistent application of criteria.
- Implement workflow improvements that streamline utilization processes, reduce denial rates, and enhance provider and member satisfaction.
- Oversee audit and quality review programs to maintain documentation integrity and compliance with regulatory requirements.
- Analyze utilization data and present key performance metrics to leadership, driving continuous improvement and operational excellence.
- Conducted performance evaluations, providing feedback to support employee development.
Episodic Care Manager
Blue Cross Blue Shield of North Carolina
07.2007 - 07.2023
- Reviewed and authorized medical necessity determinations for skilled nursing, DME, and infusion services across state and commercial lines of business, ensuring alignment with clinical guidelines and payer policies.
- Served as Subject Matter Expert (SME) for discharge processes, compliance oversight, and PDN audit reporting, contributing to regulatory accuracy and quality outcomes.
- Trained, mentored, and cross-trained new team members, promoting professional growth, knowledge sharing, and operational consistency.
- Supported enterprise-wide initiatives, including system migrations, to ensure seamless workflow continuity and compliance during organizational transitions.
Appeals Analyst II
Blue Cross Blue Shield of North Carolina
07.2006 - 07.2007
- Independently managed Level II medical appeals, preparing and presenting complex cases to Medical Directors and Legal teams for review and resolution.
- Coordinated Level III NCDOI (North Carolina Department of Insurance) reviews, ensuring complete documentation, regulatory accuracy, and timely case processing.
- Streamlined appeals workflows by improving documentation standards and implementing enhanced tracking systems, resulting in greater efficiency and transparency.
Staff Nurse
Moses Cone Health System
12.2003 - 07.2006
- Delivered complex post-surgical and critical care in a high-acuity step-down ICU, ensuring patient safety, stabilization, and optimal recovery outcomes.
- Served as charge nurse and clinical preceptor, providing leadership, mentorship, and support to nursing staff and new graduates.
- Expertly managed advanced clinical interventions, including chest tubes, cardiac drips, ventilators, and continuous telemetry monitoring.
- Maintained current certifications in BLS, ACLS, and EKG/Telemetry, demonstrating commitment to clinical excellence and professional standards.
Education
Bachelor of Science - Nursing
University of North Carolina At Greensboro
Greensboro, NC01-2001
Skills
- 18 years of experience in healthcare payer operations and utilization management
- Proficient in applying evidence-based practices to enhance payer workflows and decision accuracy
- Expertise in prior authorization, denial prevention, and secondary clinical review
- Strong knowledge of CMS and NCQA standards, regulatory compliance, and accreditation processes
- Collaborative leader experienced in uniting cross-functional teams to achieve operational goals
- Technically adept in workflow optimization, software evaluation, and process automation
- Expertise in team leadership, workload distribution, and process coordination to enhance productivity and operational alignment
- Analytical thinker skilled at translating performance data into actionable training and process improvements
Timeline
Supervisor, Clinical Teams
Blue Cross Blue Shield of North Carolina
07.2023 - Current
Episodic Care Manager
Blue Cross Blue Shield of North Carolina
07.2007 - 07.2023
Appeals Analyst II
Blue Cross Blue Shield of North Carolina
07.2006 - 07.2007
Staff Nurse
Moses Cone Health System
12.2003 - 07.2006
Bachelor of Science - Nursing
University of North Carolina At Greensboro