Summary
Overview
Work History
Education
Skills
Certification
Timeline
Generic

Jessica Berben

Delmar,NY

Summary

Seasoned nursing professional offering proven clinical knowledge, natural interpersonal strengths, and technical abilities.

Knowledgeable in Microsoft Word, Excel, Windows, Outlook, EMR charting, medication administration, and interdisciplinary collaboration focused on optimizing patient care and support.

Previously experienced with Visual Cactus, Macess, Amisys, MaxMC, Siebel, and Caresync.

Quality-focused and efficiency-driven leader. Organized and dependable candidate successful at managing multiple priorities with a positive attitude.

Willingness to take on added responsibilities to meet team goals.

Detail-oriented team player with strong organizational skills. Ability to handle multiple projects simultaneously with a high degree of accuracy. To seek and maintain a full-time position that offers professional challenges utilizing interpersonal skills, excellent time management, and problem-solving skills.

Overview

23
23
years of professional experience
1
1
Certification

Work History

Clinical Nurse Reviewer, Grievance and Appeals

EmblemHealth
04.2017 - Current
  • Improved patient care quality by conducting thorough clinical reviews and providing evidence-based recommendations.
  • Investigated and responded to medical necessity issues raised by members and medical providers in grievance and appeals correspondences: review all member and provider grievances, first, second level, and expedited appeals; retrospective utilization reviews for GHI, HIP, and Connecticare lines of business timely which included Commercial, Medicare, and Medicaid lines of business.
  • Reduced hospital readmission rates by identifying trends through comprehensive case reviews and recommending interventions.
  • Enhanced interdisciplinary communication by collaborating with medical directors to discuss case review findings and provide clinical recommendations for final determinations to meet regulatory and departmental timeframes. Decisions were based on medical necessity and specific criteria i.e.: MCG (Milliman Care Guidelines), CMS (Centers for Medicare and Medicaid Service), EmblemHealth internal Criteria, and previously utilized InterQual criteria.
  • Trained and mentored new clinical employees in the Grievance and Appeals Department.
  • Worked after hours, weekends, and holiday On-Call to process Expedited Appeals timely and offered availability to weekend shift nurses who required assistance.
  • Referred cases to external Independent Review organizations (IROs) and MFSI (Maximus Federal Services, Inc).
  • Attended non-mandatory webinars and obtained Continuing Education Units (CEUs) to maintain current knowledge base.
  • Precise documentation in Compliant Appeals and Grievances systems and Clinical CareAdvance (CCA) to ensure timely claim payments.
  • Increased efficiency in the review process by streamlining workflows and implementing time-saving strategies for data collection and analysis.
  • Optimized resource allocation by identifying areas of overutilization or underutilization within the healthcare system.
  • Strengthened professional development with ongoing education in disease management, treatment protocols, and emerging trends in nursing practice.
  • Promoted patient safety by actively participating in root cause analyses to identify potential risks or gaps in care delivery.
  • Supported continuous improvement initiatives by contributing to the development of policies, procedures, and training materials related to clinical review processes.
  • Demonstrated expert knowledge of medical terminology, pharmacology, anatomy, and physiology while conducting accurate clinical assessments.
  • Advanced organizational goals for quality improvement by serving as a liaison between nursing staff, physicians, administrators, and patients during the review process.
  • Managed caseload efficiently while maintaining strict confidentiality of sensitive information per HIPAA regulations.
  • Built trust among team members by consistently demonstrating professionalism, integrity, and commitment to excellence throughout the clinical review process.
  • Contributed to cost containment efforts by identifying opportunities for more effective utilization of healthcare services without compromising patient outcomes.
  • Proactively addressed potential barriers to care coordination by facilitating open communication between stakeholders involved in each case review.
  • Conducted in-depth research on emerging medical trends and best practices, sharing findings with colleagues to inform clinical decision-making processes.
  • Adhered to strict timelines for case completion while maintaining a high level of accuracy and attention to detail during the review process.
  • Reviewed and documented relevant information into data system applications.
  • Contacted providers, state agency offices and applicants to obtain information and records needed to conduct comprehensive clinical review of case and final determination.
  • Determined and authorized services for patients in accordance with guidelines and regulations.
  • Conducted routine and ad-hoc evaluations and re-evaluations of services.
  • Evaluated patient histories, complaints, and current symptoms.
  • Communicated with healthcare team members to plan, implement and enhance treatment strategies.
  • Followed all personal and health data procedures to effectively comply with HIPAA laws and prevent information breaches.
  • Served as a subject matter expert on evidence-based practices for specific disease states, providing guidance and support to healthcare providers seeking to optimize patient care.

Complex Care Manager

EmblemHealth
08.2007 - 04.2017
  • Performed job duties related to solid organ and stem cell transplant, Disease Management, hospital discharge planning, Home Health Care, Durable Medical Equipment, Home Infusion, Hospice, Prenatal and postpartum care, Concurrent review, Prior Authorizations, and retrospective reviews in all fields.
  • review the appropriate DRG based on the diagnosis and/or procedure
  • Liaison to provide direct support to contracted vendors of EmblemHealth
  • Presented cases monthly during Case management Grand Rounds to medical directors and coworkers for review and learning.
  • Review, authorize, and deny concurrent review for inpatient
  • Enhanced patient care by developing and implementing individualized care plans.
  • Improved patient satisfaction through effective communication and collaboration with interdisciplinary healthcare teams.
  • Reduced hospital readmission rates by providing comprehensive discharge planning and follow-up support.
  • Streamlined care coordination processes, resulting in timely referrals and access to appropriate resources.
  • Promoted patient self-management by providing education on chronic condition management and healthy lifestyle choices.
  • Managed complex caseloads, ensuring timely assessment, intervention, and documentation for optimal care outcomes.
  • Collaborated with Medical Directors, supervisors and managers on complex cases to secure authorization for necessary services, maximizing patients'' benefits coverage.
  • Conducted thorough assessments to identify patients'' needs, strengths, and barriers to achieving optimal health outcomes.
  • negotiated Single Case Agreements with nonparticipating providers, facilities, and vendors.
  • Performed case management duties after hours for on-call coverage.
  • participated in training new colleagues.
  • Monitored patient progress closely, adjusting care plans as needed to promote ongoing improvement.
  • Developed strong rapport with patients and families through empathetic listening and compassionate communication techniques.
  • Implemented evidence-based interventions for diverse populations, supporting culturally competent care delivery practices.
  • Maintained up-to-date knowledge of community resources by networking with local organizations and attending professional development opportunities.
  • Utilized electronic health records systems proficiently for efficient documentation of clinical information according to regulatory standards.
  • Served as a liaison between patients, families, physicians, insurance providers, and other healthcare professionals for seamless care coordination efforts.
  • Maintained strict adherence to professional ethics and confidentiality guidelines, safeguarding sensitive information and promoting trust.
  • Participated in interdisciplinary case conferences fostering teamwork collaboration sharing best practice insights to optimize patient care outcomes.
  • Prioritized time management effectively balancing competing demands within dynamic fast-paced healthcare environments.
  • Educated clients and families on community resources, treatment options and health care services to better manage conditions.
  • Participated in team meetings and trainings to stay updated on best practices and new developments in care management.
  • Responded to emergency situations and provided support to promote client safety and wellbeing.

Licensed Practical Nurse

Prime Care Physicians
08.2001 - 08.2007
  • Improved patient outcomes by administering medications, monitoring vital signs, and documenting relevant information.
  • Assisted physicians with diagnostic testing and procedural support for optimal treatment decisions.
  • Collaborated with interdisciplinary healthcare teams to ensure continuous quality improvement in patient care delivery.
  • Instructing and Certifying coworkers and Prime Care Employees in CPR and First Aid

Education

Bachelor of Science - Health Administration

Trident University International
Cypress, CA
02.2024

Associate of Science -

Hudson Valley Community College
Troy, NY
2006

Certification - Practical Nursing

Samaritan Hospital School of Nursing
Troy, NY
01.1996

Skills

  • Nursing Staff Management
  • Medical Consultation
  • Conducting Reviews
  • Staff Education
  • Microsoft Office
  • CMS Guidelines
  • Medication Review
  • Treatment Recommendations
  • Medical Records Review
  • Review Processes
  • Specialized Healthcare Referrals
  • Patient Care Assessment
  • Patient Care Oversight
  • Case Evaluations
  • Accurate Documentation

Certification

Certified MCG (Milliman Care Guidelines) Healthcare Provider Since 2021

Timeline

Clinical Nurse Reviewer, Grievance and Appeals

EmblemHealth
04.2017 - Current

Complex Care Manager

EmblemHealth
08.2007 - 04.2017

Licensed Practical Nurse

Prime Care Physicians
08.2001 - 08.2007

Bachelor of Science - Health Administration

Trident University International

Associate of Science -

Hudson Valley Community College

Certification - Practical Nursing

Samaritan Hospital School of Nursing

Certified MCG (Milliman Care Guidelines) Healthcare Provider Since 2021

Jessica Berben