Joseph Corbin
Rio Rancho,NM
Summary
Skilled Clinician well-versed in evaluating the complete picture of a patient's life and health in order to provide treatment to the whole person. Proficient in both medical and non-medical treatments to deal with a wide range of concerns and improve health and well-being.
Overview
41
41
years of professional experience
1
1
Certification
Work History
Care Review Clinician Team Lead, Subject Matter Expert
Molina Healthcare Marketplace Central Review
01.2022 - Current
- Functioned as a liaison and knowledge source for medical directors and various departments, promoting effective communication and collaboration.
- Monitor incoming unassigned queue workload and assigned reviewer queues, move and assign cases depending on the current day’s staffing.
- Managed workflow distribution across various systems.
- Developed and implemented process improvements to enhance workflow efficiency.
- Trained new team members on department processes and guided application of review criteria to ensure compliance.
- Assist corporate training department in understanding marketplace processes, participate in leadership team meetings.
- Participate in software development work groups.
Care Review Clinician
Molina Healthcare Marketplace Central Review
12.2020 - Current
- Perform reviews of submitted pre-service requests for surgical procedures and medical treatments done in outpatient and inpatient settings.
- Apply appropriate criteria to the review such as Evidence of Coverage (contract), medical policy and MCG.
- Reviewed the case and processed it as approved upon meeting the criteria.
- Compiled case documentation for MD review and forwarded to the relevant state MD.
- Then if fully approved, partially approved or denied it is processed appropriately and all notifications made.
- If it is an approved case for a non-contracted provider or facility a single case agreement is initiated and forwarded to provider contracting.
- If a decision is overturned in a peer to peer review it is then processed as an approval with documentation made.
- Also stay up to date with all updates and changes to policy and procedures as well as annual education requirements.
- Trained new staff on UM process, reviews, software use, criteria location, and documentation standards.
- Assist in implementation of new software.
- Processed incoming faxes to ensure timely handling of requests., build authorizations.
- Ensure accuracy of authorizations.
- Acted as a resource for clerks and care review processors by providing guidance on unusual cases and answering questions.
- Provided support to CRCs by answering questions about processes and documentation with questions about processes, criteria, documentation and requested procedures.
- Have also assisted other departments and state plans find criteria and and sources for rules and regulations after hours.
LPN Charge Nurse
The Retreat Healthcare
Rio Rancho, NM
04.2020 - 12.2020
- Provided direct patient care, administered medications, treated wounds, and implemented preventative skin care.
- Supervised direct care staff in their assigned duties, delegating tasks based on patient needs.
- Assess patient psychosocial, mental and physical statuses, report to management staff, doctors and families.
- Review new doctors’ orders, write orders for medications and treatments, disseminate orders to the correct entities.
- Recorded patients’ current statuses, updated care plans, and conducted thorough assessments.
- Document in written charts and electronic records.
- Monitor meal intake and physical functioning status of patients.
- Ensure safety and security of patients, visitors and staff.
- Requested medication refills for patients from pharmacies.
LPN Nurse Auditor
Lovelace Health System
Albuquerque, NM
08.2017 - 03.2018
- Audited specific departments in 19 hospitals under Ardent Health, prepared reports, conducted preliminary findings meetings, developed corrective action plans, and facilitated exit meetings.
- Reviewed billing, coding, and medical records for accuracy and completeness of supporting charges.
- Adjusted billing charges for accuracy by identifying under billed and over billed items in patient accounts.
- Utilized predictive software for identifying missing charges, verified accuracy, and ensured correct charges were added.
- Collaborated with billing and coding departments nationwide to enhance accuracy and compliance in medical billing.
- Utilize CPT, ICD-10, and HCPC coding as well as extensive use of many different electronic medical records and Microsoft Office.
Medical Review LPN
Blue Cross Blue Shield of New Mexico
Albuquerque, NM
05.2015 - 07.2017
- Reviewed nursing facility level of care documentation to ensure compliance with standards. (Nursing Facility Level of Care), SNF (Skilled Nursing Facility), acute rehab continued stays, long term acute care continued stays (LTAC), and hospice documentation under Centennial Care Medicaid.
- Ensured nursing facilities submitted correct paperwork and that documentation supported member's need for Nursing Facility Level of Care.
- Skilled Nursing Facility, Long Term Acute Care and Acute Rehab stays are determined by use of MCG Guidelines, then regulations, facility contracts, Blue Cross and Blue Shield medical policy and clinical judgement.
- Requested additional documentation to clarify the member's level of care needs. to support the requested level of care when initial documentation was insufficient.
- Verified compliance with established regulations during documentation reviews. with hospice regulations during documentation review and confirmed submission of correct paperwork.
Fee for Service, Care Review Specialist, UM Nurse Reviewer
Quails Health
Albuquerque, NM
01.2015 - 06.2015
- Reviewed level of care eligibility and DD Waiver budgets in Fee for Service environment.
- Ensured qualification for services by verifying level of care and appropriateness of budget items.
- Conducted therapy sessions and DME utilization management reviews to evaluate patient needs.
- Prepared notifications of approvals and denials for individuals and the State of New Mexico Income Support Division.
- My strong background in software use has made me useful in training new staff and my prior knowledge of the systems has made me a valuable support to staff who are new to the Fee for Service environment.
- Developed procedures to enhance operational efficiency and support team effectiveness.
Fee For Service and Centennial Care, Care Review Clinician II, UM Nurse Reviewer for LTC
Molina Healthcare of New Mexico
Albuquerque, NM
01.2013 - 01.2015
- In the Fee for Service environment I reviewed both Nursing Facility and Personal Care Options services submissions for level of care.
- First ensuring they meet NFLOC then deciding if it was High or Low Nursing Facility level of care if it was for facility based care.
- Under Centennial Care I primarily reviewed for NFLOC for Personal Care Services in the Agency Based Community Benefits program, allocate minutes, and then send the Care Coordinator and Care Review Processors notifications or denials to be sent out.
- Prepared notifications of approvals and denials for individual facilities and members, and faxed or mailed them.
- Reviewed fair hearings as part of the process to defend decisions made to deny requests for Personal Care Options services, with only one decision overturned.
- Coordinated training for newer staff, addressing day-to-day questions to enhance team capacity.
- Acted as the primary contact for personal care services agencies, facilitating communication and support.
- I use and interpret state regulations as it applies to each individual member.
- Prepared comprehensive documentation for denials and approvals, ensuring accuracy and compliance with regulations.
- Served as backup for nursing facility nurse reviewer, ensuring continuity of care review processes.
- Contributed to development of review processes for both programs, supported department supervisor with staff evaluations, prepared reports for state and independent audits, and conducted troubleshooting and scenario testing.
- I assist other departments with training and as a resource when staff have questions.
- Frequently helping care coordinators with documentation needs as well as electronic systems navigation.
- I did trouble shooting with systems and had a large role in development of processes.
- Developed a spreadsheet tool for pro-rating allocated member service hours when partial plan year changes are being made to allocation.
MDS Coordinator, Nurse Manager
St. Theresa Healthcare and Rehabilitation
Albuquerque, NM
01.2012 - 01.2013
- As an MDS Coordinator I assess each resident, review the medical record information for thoroughness and accuracy, interview staff and family and then compile that data into the Minimum Data Sheet form that is then transmitted to CMS where it is used for quality initiatives, quality measures and payment levels.
- I also write the comprehensive care plans for each resident.
- Managed skilled Medicare and Medicare Advantage plans, coordinated case management, and gathered information for HMO authorizations.
- Managed administrative functions as a nurse manager and provided on-call support for one week each month to address staffing issues and incidents.
- Educate staff, residents and family's as needed.
- I also often handled resident and physician concerns both by phone and in the facility.
- As a nurse manager I often covered floor nurse shifts.
- Oversaw direct care for 30 residents, supervising CNAs to ensure quality care and support.
- I administered the resident's medications, performed their treatments such as breathing treatments and wound care.
- I handled family and physician contacts and concerns.
- I also did all documentation necessary for that shift such as Medicare, Medicaid and managed care residents.
MDS Coordinator, Clinical Case Manager
The Medical Resort at Fiesta Park
Albuquerque, NM
01.2012 - 12.2012
- Conducted MDS assessments on all guests and developed care plans while training and assisting floor clinical staff with issues.
- Managed clinical case management, reviewed electronic medical records for thoroughness, trained new users on Point Click Care, and collaborated with business office manager on impacts of clinical and A/R modules.
- Facilitated utilization review meetings to assess patient care needs and service utilization. and monitoring for the facility.
- I was a system super user, clinical and AR trainer.
- Coding diagnoses into the medical record and setting the order for billing.
- Assisted in troubleshooting processes.
- I will assist with facility administration and management.
- Developed employee standards and training processes to enhance team performance.
- I also take weekend call for admissions.
Patient Systems Configurations Specialist
Sun Healthcare Group
Albuquerque, NM
01.2011 - 01.2012
- Configured electronic medical record software for accounts receivables and clinical requests to enhance operational efficiency.
- Screen requests for errors, test the configurations in alternate databases for accuracy and to ensure the setup does not adversely affect other parts of the software.
- Troubleshoot software upgrades from the vendors and act as liaison between corporate clinical staff, facility clinical staff and the software vendor.
- Troubleshoot end user issues to locate cause, possible fixes and ensure fixes are applied and effective.
- Educated non-clinical IT staff on application of clinical processes within electronic environment to improve collaboration and understanding.
- Concentrated on MDS 3.0, ICD-9, UB04, and PPS to maintain compliance with healthcare regulations.
MDS Coordinator, Wound Nurse, Charge Nurse, Floor Nurse
Sunbridge Healthcare
Albuquerque, NM
01.2008 - 01.2011
- As an MDS Coordinator I assess each resident, review the medical record information for thoroughness and accuracy, interview staff and family and then compile that data into the Minimum Data Sheet form that is then transmitted to CMS where it is used for quality initiatives, quality measures and payment levels.
- I also write the comprehensive care plans for each resident.
- In Gallup I did the long-term care resident’s assessments as well as managed care and Medicare.
- Conducted assessments and developed care plans for residents at Ladera Care and Rehab, assisting with case management and gathering information for HMO authorizations.
- Managed administrative functions as nurse manager and served as on-call nurse manager weekly, addressing staffing issues and incidents.
- Educate staff, residents and family's as needed.
- As the wound nurse when I was in Gallup I assessed each resident's skin condition, contacted physicians regarding any issue found, transcribe the order and enact it.
- I performed the wound treatments and had a very high success rate of healing.
- During this time I was also the charge nurse, managing issues that may arise on day shift and the early part of the evening shift as well as handling many physician calls and staffing issues.
- I also often handled resident and physician concerns both by phone and in the facility.
- Oversaw direct care for 30 residents as floor nurse, supervising CNAs and ensuring quality care and medication administration.
- I administered the resident's medications, performed their treatments such as breathing treatments and wound care.
- I handled family and physician contacts and concerns.
- I also did all documentation necessary for that shift such as Medicare, Medicaid and managed care residents.
- Most of my work with Sunbridge has been while using a new electronic medical record.
- I was the site contact as a super user.
Physician Substitute
DCI Plasma
Gallup, NM
01.2007 - 01.2008
- Acted as onsite first responder for emergency donor reactions during plasmapheresis, addressing situations like dehydration and anticoagulant reactions.
- Conducted donor evaluations through onsite blood work, head-to-toe physicals, and lab work reviews to assess donor suitability per company and FDA guidelines.
- Counseled donors regarding low protein levels and addressed concerns for those testing positive for communicable diseases.
- Certified to manage reception, lab processing, and donor floor for plasmapheresis.
- Demonstrated proficiency in the company’s computer systems.
Back Office Nurse/Float Nurse
Cigna Healthcare
Phoenix, AZ
01.2006 - 01.2007
- Took vital signs and assessed patients, contacting primary physician for follow-up to facilitate timely care.
- Handled nurse appointments, administering routine injections and providing wound treatments to ensure patient care.
- Roomed patients for physicians, covering staff positions during breaks or absence to maintain workflow and patient service.
- Coordinated patient referrals to specialty physicians, managing communication with patients regarding prescription refills and appointment inquiries.
- Assisted surgeons during minor surgical procedures to ensure patient safety and efficiency.
- Completed all documentation electronically.
Pre-Admissions Coordinator
Jenny Edmondson Hospital
Council Bluffs, IA
01.2005 - 01.2006
- Contacted and assisted upcoming surgical patients, gathering medical history and current medication lists for input into electronic medical records.
- At that point I gave them pre-surgical instructions depending upon what medications they were taking and what procedures were being performed.
- Coordinated with physicians, surgery department, and scheduler to address unusual cases, conflicts, and cancellations.
- I coordinated lab work for each patient.
- I was frequently asked questions about the procedures and what to expect.
- I also monitored faxed lab work as it came in for reasons areas of concern then would contact the appropriate surgeon most often to cancel the procedure then notify the patient.
- Worked extended hours from 12 p.m. to 8 p.m. to enhance availability for patients unable to be reached during standard office hours.
- Acted as the only Licensed Practical Nurse in a team of Registered Nurses, previously designated as case managers.
- The job position title was changed to allow an LPN to work in that role.
Sales Manager
Weathercraft Roofing
Gering, NE
01.2004 - 01.2005
- Generated sales by actively engaging potential customers, contributing to overall revenue growth.
- Supervised multiple roofing crews while increasing sales outreach through additional calls.
- I took measurements, assessed the current roof condition and wrote out an estimate of repair on the spot.
- Escorted work crew to job sites to ensure proper execution and equipment availability.
- At this time needing a break from nursing I traveled Nebraska, Wyoming and South Dakota performing estimates on residential and commercial roofs.
Charge Nurse, Nurse Manager and a night shift house supervisor
Long Term Care
Scottsbluff, NE
01.2000 - 01.2003
Floor Nurse
Regional West Medical Center
Scottsbluff, NE
01.1994 - 01.1999
Tire Serviceman and Mechanic
Scottsbluff, NE
01.1986 - 01.1992
Security Police Specialist
United States Air Force
Cheyenne, WY
01.1985 - 01.1987
Education
Certification in Intravenous Therapy - Intravenous Therapy
Western Nebraska Community College
05.1996 - 08.1996
Practical Nursing Program - Diploma program
Western Nebraska Community College
Scottsbluff, NE 08.1992 - 08/1994
High School -
Holyoke High School
Holyoke, CO 09.1982 - 05/1985
Skills
- Care review criteria
- Utilization management
- Medical policy interpretation
- Process improvement
- Electronic medical records
- Interdepartmental collaboration
- Staff training and development
- Leadership skills
- Effective communication
- Critical thinking
- Time management
- Attention to detail
- Patient care
- HIPAA
- Organizing staff schedules
- Multidisciplinary approach
- Individual instruction
- Healthcare systems navigation
- Technology proficiency
- Medical recordkeeping
- Records management
- Learning management systems
Certification
LPN, 10/94, Present
References
Available upon request
Timeline
Care Review Clinician Team Lead, Subject Matter Expert
Molina Healthcare Marketplace Central Review
01.2022 - Current
Care Review Clinician
Molina Healthcare Marketplace Central Review
12.2020 - Current
LPN Charge Nurse
The Retreat Healthcare
04.2020 - 12.2020
LPN Nurse Auditor
Lovelace Health System
08.2017 - 03.2018
Medical Review LPN
Blue Cross Blue Shield of New Mexico
05.2015 - 07.2017
Fee for Service, Care Review Specialist, UM Nurse Reviewer
Quails Health
01.2015 - 06.2015
Fee For Service and Centennial Care, Care Review Clinician II, UM Nurse Reviewer for LTC
Molina Healthcare of New Mexico
01.2013 - 01.2015
MDS Coordinator, Nurse Manager
St. Theresa Healthcare and Rehabilitation
01.2012 - 01.2013
MDS Coordinator, Clinical Case Manager
The Medical Resort at Fiesta Park
01.2012 - 12.2012
Patient Systems Configurations Specialist
Sun Healthcare Group
01.2011 - 01.2012
MDS Coordinator, Wound Nurse, Charge Nurse, Floor Nurse
Sunbridge Healthcare
01.2008 - 01.2011
Physician Substitute
DCI Plasma
01.2007 - 01.2008
Back Office Nurse/Float Nurse
Cigna Healthcare
01.2006 - 01.2007
Pre-Admissions Coordinator
Jenny Edmondson Hospital
01.2005 - 01.2006
Sales Manager
Weathercraft Roofing
01.2004 - 01.2005
Charge Nurse, Nurse Manager and a night shift house supervisor
Long Term Care
01.2000 - 01.2003
Certification in Intravenous Therapy - Intravenous Therapy
Western Nebraska Community College
05.1996 - 08.1996
Floor Nurse
Regional West Medical Center
01.1994 - 01.1999
Practical Nursing Program - Diploma program
Western Nebraska Community College
08.1992 - 08/1994
Tire Serviceman and Mechanic
01.1986 - 01.1992
Security Police Specialist
United States Air Force
01.1985 - 01.1987
High School -
Holyoke High School
09.1982 - 05/1985