Registered nurse with 18+ years of broad organizational experience, including direct patient-oriented care, Case Management from a Managed Care, Group Health, and Medicare/Medicaid arena. Contributes diverse capabilities including strong organizational skills, effective communication, time management prioritizing, complex problem-solving skills, with attention to detail, knowledge of payment, and advance computer literacy skills. Demonstrates competency all along the healthcare continuum including: Working in close conjunction with Physicians and the healthcare support team, Pre-Certification and Utilization Management, Case Management, Patient Advocacy and Education, and Discharge Planning, Extensive knowledge of regulatory compliance, claim adjudication, and proficiency of the Member/Provider Appeals and Grievance processes. Seasoned nursing professional offering proven clinical knowledge, natural interpersonal strengths and technical abilities. Knowledgeable about EMR charting, medication administration and interdisciplinary collaboration focused on optimizing patient care and support. Quality-focused and efficiency-driven leader.
Hi, I’m
Jami Fitch
Green Cove Springs,FL
Summary
Overview
18
years of professional experience
1
Certificate
Work History
Florida Blue
Healthcare Appeals Analyst RN
10.2016 - 03.2024
Job overview
- Review and assist appeal coordinators in clinical research and processing of appeals in accordance with CMS guidelines, Employee Retirement Income Security Act (ERISA), Health Insurance Portability and Accountability Act (HIPPA), and corporate/departmental standards
- Review for CMS-1500 or equivalent electronic counterpart for proper coding
- Collaborates in accordance with business partners including: third party vendors, medical offices, and hospitals across continuum as needed to gather medical documentation to help assist Medical Director in processing final appeal determination
- Follows all regulatory requirements as appropriate in accordance with corporate values policies and procedures
- Interviewed agents and claimants to correct errors or omissions and investigate questionable claims.
- Conducted day-to-day administrative tasks to maintain information files and process paperwork.
- Accessed JIVA, Seible, Prime, MCG, InterQual, Legacy and/or Diamond systems as part of clinical research to ensure accurate claims adjudication, reducing errors and inconsistencies in review process.
- Enhanced customer satisfaction with timely resolution of appeals, addressing concerns thoroughly and professionally.
- Mentored new team members on departmental protocols and best practices, fostering positive learning.
- Managed high volume of cases, prioritizing tasks effectively and meeting strict deadlines for appeals resolutions.
- Handled escalated cases adeptly, applying advanced problem-solving skills to resolve highly complex or contentious issues.
- Maintained detailed records and organized documentation to facilitate smooth appeals processing, ensuring all relevant information was readily available for review.
- Collaborated with interdisciplinary teams for comprehensive patient care plans, resulting in better health outcomes.
- Worked flexible hours across night, weekend, and holiday shifts.
United Healthcare
Transitional Field Based Case Manager
08.2015 - 10.2016
Job overview
- Provides assessments of physical, psycho-social, and transition needs in settings limited to inpatient hospital admission and first physician follow up post discharge to next level of care
- Develops interventions and processes to assist Health Plan and/or member, prevent readmission in the first 30 days post discharge
- Serves as clinical liaison with hospital, clinical, and administrative staff, as well as provides expertise for clinical authorizations for inpatient care
- Stratifies and/or validates patient level of risk and communicates during transition process with IDT Coordinates and attends member visits with PCP and specialists as needed
- Manages assigned case load in efficient and effective manner
- Referred members with complex illnesses or newly diagnosed diseases to Disease Management Program for ongoing care.
- Assisted in development of nurse navigation program, streamlining patient care coordination.
- Built partnerships with local agencies and groups to assist with patient care, support or educational needs.
- Conveyed treatment options, diagnosis information and home care techniques to patients and caregivers to continue care consistency.
- Collaborated with multidisciplinary teams to optimize patient care and support services.
- Promoted patient and family comfort during challenging recoveries to enhance healing and eliminate non-compliance problems.
- Streamlined communication between healthcare teams, ensuring timely updates on patient progress and needs.
- Monitored patient progress closely, adjusting care plans proactively in response to changing needs or concerns.
Orange Park Medical Center
Hospital Case Manager/ Utilization Management
03.2014 - 07.2015
Job overview
- Coordinated patient discharge with post- discharge services and care instructions
- Facilitated integration and coordination of care between various health care services
- Maintained positive relationships and communication with team members
- Delivered high-quality and compassionate care to indigent, under insured, and low-income patient community and assist them with their discharge planning needs
- Assisted patients to locate community resources for multiple chronic diseases including COPD, DM, CHF, and Asthma
- Interviewed clients individually and with families to determine what services would best address their discharge needs
- Advised patients on community resources, and made referrals as appropriate, coordinating care with vendors including Skilled Nursing Facilities, Inpatient Rehabilitation Facilities, Home Infusion companies, and DME providers
- Participates in evaluating opportunities to optimize utilization and reimbursement across population of patients to meet organizational strategic objectives, and to identify and prevent avoidable days
- Provided leadership, guidance and support to staff members.
- Strengthened relationships with community organizations to increase access to supportive resources for clients in need.
- Evaluated treatment plans against individual goals and healthcare standards.
- Collaborated with interdisciplinary team to determine timely delivery of services.
- Partnered with local organizations to expand access to social and community services.
- Identified care needs of individual patients and coordinated responses based on physician advice, insurance limitations, and procedural costs.
Florida Blue
Medical Review Nurse
03.2011 - 03.2014
Job overview
- Research, resolve, and authorize medical clearances requiring medical decision making
- Consult with Medical Director and other resources on issues related to medical clearances, Voluntary Pre-Service reviews/determinations, claims disposition, and member or provider appeals
- Actively participated in Pre-Service unit-based Medicare Quality Assurance Program, as the primary Medicare Review Nurse
- Developed and maintained quality care systems and standards, including but not limited to, creating and improving medical protocols/guidelines
- Performed all tasks with a patient-centered focus while seeking opportunities for improvement of policies and procedures
- Facilitated timely claim resolution for patients by collaborating with insurance companies and healthcare providers.
- Assisted in staff training and development programs, sharing expertise on best practices in medical review nursing procedures.
- Enhanced patient care by conducting thorough medical record reviews and identifying discrepancies or inconsistencies.
- Evaluated patient histories, complaints, and current symptoms.
- Increased accuracy in billing processes by verifying correct coding practices within reviewed medical records.
- Communicated with healthcare team members to plan, implement and enhance treatment strategies.
- Quickly responded to situations impacting safety and security to unit, actualizing crisis prevention interventions to control and de-escalate situations.
- Equipped patients with tools and knowledge needed for speedy and sustained recovery.
- Provided expert consultation on medical necessity determinations for various treatments and interventions during case evaluations.
Florida Blue Retail Center
Nurse Navigator
04.2010 - 03.2011
Job overview
- Performed pre- and post-procedure calls for optimal patient outcomes and experience
- Provided patients and their family members with relevant instructions and education
- Evaluated/Educated patients identified through personal health assessments of chronic conditions including hypertension, asthma, CHF, and diabetes
- Provided education to patients on current education topics effecting the community ie; breast cancer awareness, with clinical presentations providing health education through weekly health seminars
- Provided necessary health education training for patients
- Supported and empowered patients by educating them on available patient teaching tools that include: online self-assessment tools, medical topic education, and access to personal claim information
- Responsible for offering network options for members who need primary care, specialist, case management or a disease management specialist
- Assisted members with identifying reductions in cost for outpatient diagnostic procedures and medications.
- Served as a liaison between patients, families, and healthcare providers to ensure seamless communication and continuity of care.
- Provided ongoing assessment of patients'' needs, adjusting care plans accordingly to promote optimal health outcomes.
- Scheduled appointments, educational meetings, and follow-ups for patients and family members.
Blue Cross Blue Shield
Medical Review Nurse
06.2007 - 04.2010
Job overview
- Research, resolve, and authorize medical clearances requiring medical decision making, working directly with providers and Florida Blue internal resources
- Consult with Medical Director and other resources on issues related to medical clearances, Voluntary pre service review, and Claims disposition
- Identify emerging technologies and newly FDA approved pharmaceuticals and coordinate with the appropriate department for updating Medical Coverage Guidelines, and claims pricing as needed
- Teach/mentor new hires on interdepartmental processes, systems training, daily job requirements, desktop reviews, interpretation of group specific contract benefits and medical terminology
- Submitted recommendations for process improvements through the Continuous Quality Improvement (CQI) process
Baptist Medical Center Jacksonville
Registered Nurse Women's Surgical Unit
10.2005 - 06.2007
Job overview
- Analyzed records data and reports in order to identify health care needs and deliver optimum patient care
- Applied clinical expertise in executing orders including wound care, intravenous therapy, ventilation care, catheterization, and pain management techniques
- Assisted the physician with procedures, when needed
- Built cooperative relationships and rapport with physicians, health care staff, and patients to actively communicate information and address any issues or needs, in order to meet and exceed expectations
- Clearly communicated with supervisors, health care providers, patients, and family members about patient needs and progress
- Coordinated patient discharge with post-care instructions
- Demonstrated safe and responsible use of equipment; maintained infection control and safety measures with every single patient contact
- Evaluated emergency situations and started appropriate nursing interventions.
- Collaborated with physicians to quickly assess patients and deliver appropriate treatment while managing rapidly changing conditions.
- Led teams in driving successful patient outcomes by prioritizing standard of care and best practices.
- Provided didactic and clinical instructions to orient new nurses and potential student nurses to achieve training outcomes.
- Organized and managed care of patients undergoing various therapies and procedures.
- Streamlined medication administration processes for increased safety and accuracy during busy shifts.
- Conducted thorough patient assessments to identify changes in condition, promptly notifying physicians and initiating appropriate interventions when necessary.
- Served as a preceptor for nursing students during their clinical rotations, providing valuable real-world experience and guidance to foster professional growth.
- Administered medications via oral, IV, and intramuscular injections and monitored responses.
- Contributed to interdisciplinary team meetings by presenting relevant clinical data about patients'' progress toward reaching established goals of care.
Education
American Nurses Credentialing CenterSilver Spring, MD
Nursing Case Management
02.2016
University Overview
St. Johns River State CollegeOrange Park, FL
Associates of Nursing
08.2005
University Overview
- Honors: Graduated Magna Cum Laude
- GPA: 3.78
Skills
Health and wellness expertise
Case Management/ Nurse Navigator experience
Committed to compliance reporting
Familiarity with disease management programs
Dedicated to patient advocacy and education
Broad medical terminology knowledge/ICD-10
Passionate and Empathetic caregiver
Proficient in InterQual/Manage Care/ Group or Individual Health plans/Florida Blue Medical Coverage Guidelines-Milliman Guidelines
Claims Evaluation
Records Review
Critical Thinking
Coaching and Mentoring
Case Evaluation
Benefits review
Computer Skills
Coverage Determination
Team Collaboration
Policy Interpretation
Claims adjustment
Certification
- Basic Life Support (CPR and AED) Program- Issued 12/13/2023
Timeline
Healthcare Appeals Analyst RN
Florida Blue
10.2016 - 03.2024
Transitional Field Based Case Manager
United Healthcare
08.2015 - 10.2016
Hospital Case Manager/ Utilization Management
Orange Park Medical Center
03.2014 - 07.2015
Medical Review Nurse
Florida Blue
03.2011 - 03.2014
Nurse Navigator
Florida Blue Retail Center
04.2010 - 03.2011
Medical Review Nurse
Blue Cross Blue Shield
06.2007 - 04.2010
Registered Nurse Women's Surgical Unit
Baptist Medical Center Jacksonville
10.2005 - 06.2007
American Nurses Credentialing Center
Nursing Case Management
St. Johns River State College
Associates of Nursing
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