Jennifer Bruner, BSN, RN

Supervisor-April 2015-September 2018

Team Lead- April 2014

Prepay Review Nurse- August 2004

• Managed and motivated employees to be productive and engaged in work.
• Accomplished multiple tasks within established timeframes.
• Maintained professional, organized, and safe environment for employees and patrons.
• Monitored and analyzed business performance to identify areas of improvement and make necessary adjustments.
• Developed strong company culture focused on employee engagement, collaboration, and continuous learning opportunities.
• Achieved departmental goals by developing and executing strategic plans and performance metrics.
• Performs oversight, audits and tracking of medical necessity reviews to ensure timeliness and submits monthly report.
• Assists beneficiaries, providers, DHA, NQMC, PGBA, WPS, VO and associates regarding utilization processes.
• Facilitate authorizations/claims to be contracted Physician Reviewers, along with any pertinent faxes or letters, for review.
• Develop and maintain working relationships with external/internal customers.
• Develops innovative ideas and works with Supervisors, Director and Executive Director to complete special projects.
• Collaborates with PGBA, Claims Oversight, Project Managers and Consultants to achieve viable processes and guidelines for Pre-Payment Review and Medical Records Department pertaining to T5 contract.
• Review claims electronically to determine medical necessity and/or benefit coverage for services such as cosmetic procedures, physical therapy, durable medical equipment, ambulance transports, and inpatient admissions.
• Process authorizations for medical services within established regulatory timeframes.
• Participated in WAH Pilot Program that was started in 2009
• Completed referral authorization entry for EWRAS at beginning of South Contract.
• Conducted concurrent review and discharge planning for Gulf south Market office after Hurricane Katrina disaster.
• Review and complete claim appeals/reconsiderations when submitted by members or providers.
• Served as preceptor for new Prepay nurses.
• Participated in startup of claims unit and assisted in developing processes that are in place today.

• Assessing, planning, implementing, coordinating, and monitoring health care services to meet individual's health needs through communication and available resources to promote quality, cost-effective outcomes.
• Conducts telephonic review to obtain primary admitting diagnosis, clinical history, treatment plan and proposed length of service for inpatient hospital admissions and outpatient services.
• Conducts negotiations on precertification and small case management cases with non-PPO provider's i.e. DME or Home Health.
• Work collaboratively with providers, social agencies, community resources, and patient's personal support network to assist patients and their families access needed services, optimize effective self-care strategies, identify options and make choices that reflect their needs and priorities.
• Optimize patient's compliance, self-management abilities and response to treatment through direct education, coordination of resources, and strengthening of patient/family coping mechanisms.
• Educate and support patient and/or family as to their rights and alternatives throughout case management process.
• Perform case management services in professional manner consistent with departmental policies and procedures, and URAC guidelines for practice of case management.
• Function as supportive resource to patients, providers, and facility personnel with respect to case management process and facilitate communication between these individuals and health plan staff, such that issues any of eligibility, coverage, precertification review, claims and services are resolved.
• Perform accurate and complete verification of eligibility and coverage and alternative resources and apply this information to precertification, discharge planning, and case management process.
• Worked with senior citizens with average age of 75.
• Provided assistance to senior citizens on DME, provider relations, and coordination of care.