Joy Anderson
Phoenix
Summary
Experienced Clinical Nurse with over nine years of expertise in Community & State Medical Policies and Programs. Proven track record in managing Medicaid state guidelines, regulatory compliance, and policy development. Adept at solving complex problems, leading cross-functional teams, and developing innovative solutions. Strong interpersonal and communication skills, with a focus on delivering excellent customer service and exceeding regulatory expectations.
Overview
17
17
years of professional experience
1
1
Certification
Work History
Clinical Quality RN
UnitedHealthcare Community Plan
01.2022 - Current
- Oversight and project support for regulatory policies and procedures, including tracking AHCCCS and DDD policy implications
- Manage over 75 policies, 42 SOP documents, and 31 NCQA National Policies with AZ Riders
- Serve as the central collaborative point of contact for Health Services medical regulatory policy/procedure, workflows, and contract revisions
- Lead monthly meetings with Health Services Teams to monitor regulatory reporting and compliance
- Assist in the creation and drafting of Medical Management Annual Plan documents and evaluations
- Coordinate and organize internal responses, document retrieval, and interviews for audits and ad hoc requests by state regulators
- Communicate changes in regulatory requirements or covered benefits to external business partners
- Monitor and track projects using spreadsheets and other project management tools
- Lead functional or segment teams to complete complex projects and provide explanations on operational process changes
Preservice Review Nurse RN
United Health Group, Optum
08.2015 - 12.2021
- Performed clinical coverage review for Arizona LOBs, interpreting state and federal mandates and benefit language
- Established and maintained positive working relationships to support goals and objectives
- Member of the annual review team for Arizona State Specific Guidelines, researching and providing process updates
- Contributed to the Blue Chip project-Decisioning at Point of Care (DPOC) for prior authorization
Case Manager RN-Complex Medical Conditions Transplant
United Health Group, Optum
06.2014 - 08.2015
- Conducted initial and re-assessments for members, developing care plans and coordinating services
- Performed clinical coverage reviews for transplant evaluations and hospitalizations
- Maintained knowledge of CMS, UNOS, UHC, and state regulations related to transplants
Sr Clinical Admin Nurse RN
United Healthcare Clinical Services
11.2012 - 06.2014
- Reviewed adverse determination notices for accuracy and compliance
- Maintained knowledge of federal and state regulations, contracts, and UHG guidelines
Liver Transplant RN Coordinator
Phoenix Children's Hospital
08.2011 - 11.2012
- Lead liver transplant team member responsible for programmatic compliance to CMS, UNOS, Joint Commission, and AHCCCS regulations
- Developed policies, protocols, and order sets for the liver transplant program
- Coordinated patient care and served on multidisciplinary committees for program development
Liver & Liver/Kidney RN Transplant Coordinator
Banner Good Samaritan Medical Center Transplant
04.2008 - 08.2011
- Performed clinical transplant coordination for liver and liver/kidney patients
- Member of multidisciplinary transplant selection and quality assurance committees
Education
Associate of Science - Nursing
Florida Keys Community College
Key West, FLBachelor of Arts - Business Administration
The Evergreen State College
Olympia, WASkills
- Interpersonal Communication
- Insurance Industry Experience
- Collaborative Relationships
- Documentation and Reporting
- Written Communication
- Policy Compliance Understanding
- Organization and Time Management
- Dependable and Responsible
- Attention to Detail
- Advanced Problem Solving
- Data Collection and Analysis
- Proficient in Microsoft Word and Excel
Certification
Licensed Registered Nurse, AZ, Active, 04/01/27
Personal Information
Title: Registered Nurse
Timeline
Clinical Quality RN
UnitedHealthcare Community Plan
01.2022 - Current
Preservice Review Nurse RN
United Health Group, Optum
08.2015 - 12.2021
Case Manager RN-Complex Medical Conditions Transplant
United Health Group, Optum
06.2014 - 08.2015
Sr Clinical Admin Nurse RN
United Healthcare Clinical Services
11.2012 - 06.2014
Liver Transplant RN Coordinator
Phoenix Children's Hospital
08.2011 - 11.2012
Liver & Liver/Kidney RN Transplant Coordinator
Banner Good Samaritan Medical Center Transplant
04.2008 - 08.2011
Bachelor of Arts - Business Administration
The Evergreen State College
Associate of Science - Nursing
Florida Keys Community College
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