Summary
Work History
Education
Skills
Timeline
Hi, I’m

June "LaRail" Shipp

Registered Nurse
Stephenville,TX

Summary

Clinical Appeal Specialist/Utilization Review/Case Management recognized for strong leadership and case management and appeal letter writing skills. Motivated and results oriented with proven strengths that include CM/UR program development and implementation, developing process improvement and staff education. Strong analytical thinker, communicator and problem solver.

Experienced Commercial, Managed Care and Traditional Insurance Specialist successful at managing high caseloads in fast-paced environments. Organized, driven and adaptable with excellent planning and problem-solving abilities. Offering 31 years of experience and willingness to take on any challenge.

Work History

Ensemble Health Partners

Clinical Appeal Specialist/SMART
03.2019 - Current

Job overview

  • Clinical Denials
  • Implemented new team development of new client with 14 facilities including 3 EMRs and multiple systems housing other documents
  • Assure timeliness and appropriateness of all provider appeals according to state and federal guidelines
  • Evaluate medical necessity and appropriate levels of care and formulate conclusions
  • Research issues utilizing systems and clinical assessment skills, knowledge regarding criteria such MCG, InterQual, NCDs, LCDs and payer polices in the decision-making process regarding health care services and care provided to members
  • Coordinate workflow between departments and interface with internal and external resources
  • Receive and resolve provider inquiries related to claims
  • Maintain working relationships within various operational areas to identify and execute overall process improvements
  • Train all new team members and monitor team and individual performance and progress against goals
  • Fluent using Epic, Meditech, Cerner, Allscripts
  • Generated, posted and attached information to claim files.
  • Checked documentation for accuracy and validity on updated systems.

FirstCare Health Plans

Manager
07.2016 - 07.2018

Job overview

  • Management
  • Managed telephonic team that included one team leader, eleven case managers, two utilization review nurses and two care coordination specialists
  • Implemented new case management/utilization review model that combined the two roles being performed by one RN
  • Utilization review performed using MCG Care Guidelines
  • Abstraction of medical records for quality and chart reviews
  • NCQA, CMS knowledgeable
  • Prepared mandatory reports to the State of Texas for Early Childhood Development (ECI)
  • Developed and implemented productivity measures to ensure appropriate staffing to meet contractual requirements
  • Developed and implanted transitional care process to guide patients from acute care to post- acute facilities including LTAC, Skilled facilities and Rehab
  • Developed and implemented process for new State of Texas Adoption Assistance/Permanency Care Assistance program (AA/PCA)
  • Facilitated ongoing team building and staff training
  • Collaborated with other departments to ensure quality care to members and cost control
  • Managed and motivated employees to be productive and engaged in work.
  • Accomplished multiple tasks within established timeframes.

FirstCare Health Plans

Team Lead/Case Manager
09.2014 - 07.2016

Job overview

  • Case Management
  • Team lead of five Managed Care Medicare case managers and one Clinical Support Staff
  • Telephonic management of a case load of 200 Managed Care Medicare members
  • Improved quality of member care and decreased hospital admissions by providing coordination of services through collaboration with interdisciplinary care team
  • Established and maintained telephonic communication with members while performing case reviews as indicated
  • By utilizing Best Nursing Practices proactively assessed potential member problems and initiated solutions
  • Lead and participated in monthly and as needed Interdisciplinary Team meetings
  • Made referrals to home health care, Hospice, outpatient services and DME when appropriate
  • Coordinated services with other agencies, community-based organizations, and healthcare professionals to provide useful benefits to clients.
  • Developed and implemented comprehensive case management plans to address client needs and goals.

Covenant Health System

Case Manager/UR Nurse/Denial-Appeals Specialist/Staff Educator
09.1999 - 09.2014

Job overview

  • Case Management/Social Services
  • Performed Case Management and Utilization Review in 500 bed hospital that included both adult and pediatric ICU and acute care in various specialties including Oncology and Palliative Care
  • Average daily case load of 70
  • Provided discharge planning and performed pre-certification, concurrent and retrospective reviews applying appropriate criteria
  • Knowledgeable in all lines of business to include unfunded, Medicare, Medicaid, Managed Care and Private Insurance
  • Advanced in role to Denial Specialist/Staff Educator and performed Medicare, Medicaid and Private Insurance appeals with high turnover rate
  • Abstraction of medical records to support appeal process
  • Coordinated quality audits and Inter-rater Reliability testing of staff
  • Facilitated ongoing training and team building of staff
  • Coordinated services with other agencies, community-based organizations, and healthcare professionals to provide useful benefits to clients.
  • Developed and implemented comprehensive case management plans to address client needs and goals.

Education

Texas Tech University, Health Sciences Center

Bachelor of Science from Nursing
12.1991

University Overview

Skills

  • Software Proficiency - Meditech, Excel, Epic, Cerner, Allscripts
  • Flexible and Adaptable
  • Critical Thinking
  • Dependable and Responsible
  • Problem-Solving
  • Multitasking Abilities
  • Active Listening
  • Training and Development
  • Google Workspace

Timeline

Clinical Appeal Specialist/SMART
Ensemble Health Partners
03.2019 - Current
Manager
FirstCare Health Plans
07.2016 - 07.2018
Team Lead/Case Manager
FirstCare Health Plans
09.2014 - 07.2016
Case Manager/UR Nurse/Denial-Appeals Specialist/Staff Educator
Covenant Health System
09.1999 - 09.2014
Texas Tech University, Health Sciences Center
Bachelor of Science from Nursing
June "LaRail" ShippRegistered Nurse