Dedicated and compassionate Registered Nurse (RN, BSN) with progressive career history in direct patient care, triage and care coordination in fast-paced environment. Proven to remain calm under pressure and skillfully handle difficult patients and high-stress situations. Consistently developing strong relationships with patients and families through empathetic communication, respectful attitude and excellent customer service.
Diligent RN with solid background in utilization review and patient care coordination. Proven ability to streamline processes and enhance patient outcomes through efficient resource management. Demonstrated expertise in case management and regulatory compliance.
Skills
Proficient in Microsoft and MacBook/Google Applications
Proficient with InterQual and MCG
Highly experienced with ICD-9 and ICD-10 coding, Cpt-4, HCPC, Revenue codes, HCFA and UB-04 billing, NCDs, LCDs, DRG
Currently enrolled in AAPC CPC self-paced course
Effective communication and presentation skills across all lines of business
Supervisor experience, leadership and training, evaluations of employees
Clinical judgment
Compassion and empathy
Discharge planning
Strong clinical judgment
Excellent communication across all lines of business
Work History
Clinical review/UM RN
Cohere Health
10.2024 - 02.2025
Doing prior auth and retrospective reviews for Humana Medicare
Using MCG criteria, NCD, LCD, Humana policies
Using MacBook Pro and Google application
Coordinate care with provider offices regarding documentation needed for Medicare coverage
Assisted provider staff with obtaining the information needed for a prior authorization
Remote
Conducted comprehensive reviews of patient care plans to ensure compliance with regulatory standards.
Utilized electronic health record systems for accurate documentation and data analysis.
Collaborated with healthcare teams to evaluate treatment effectiveness and recommend alternatives.
Analyzed trends in patient care patterns to identify opportunities for improvement in service delivery.
Reduced healthcare costs through efficient utilization of resources and identification of unnecessary treatments or procedures.
Clinical Appeals RN
Aerotek Scientific
06.2024 - 10.2024
Clinical appeals RN, doing reviews for AZ Medicaid and Medicare claims
InterQual, NCD, LCD and AZ medical policies for Medicaid and Medicare
Remote position
Monitored trends in appeal outcomes to identify areas for organizational improvement.
Collaborated with legal teams to prepare documentation for contested appeals.
Collaborated with interdisciplinary teams for comprehensive patient care plans, resulting in better health outcomes.
Analyzed and processed appeals to ensure compliance with regulatory standards.
Led cross-functional teams to resolve complex appeal cases efficiently.
Clinical Risk Manager
Banner-University Medical Center Phoenix
06.2019 - 11.2023
Worked as Clinical Risk Manager for Banner Health entity BUMC-P, Behavioral Health (youth IP, adult IP—voluntary and involuntary), and Sonora Quest Laboratories
Worked closely with patient safety, especially with regards to managing unanticipated events.
Reviewed contracts for potential liabilities or exposures, recommending adjustments as necessary to minimize overall legal and financial impact on the organization.
Reviewed reports of unanticipated events/outcomes reported by staff and/or physicians. Followed up as necessary with staff/provider interviews.
Participated in Root-Cause Analysis meetings following safety events to identify needs for process improvement
Used Origami Risk to document PCE and other liability events, reports made to medical board, documentation of claims paid by Risk Management and storage of files on current open claims and/or potential claims.
Handled Medical malpractice claims according to internal risk management policies, keeping liability minimized by leveraging expertise and available tools.
Reviewed medical records for review of documentation made by staff and/or providers
Worked closely with Medical Ethics committee to provide information and resources about ethical decision-making, promoting patient rights, end-of-life decision making.
Conducted regular audits of existing policies and procedures, ensuring their continued effectiveness in addressing organizational goals related to mitigating risks.
Reported sentinel events or medical device failures to FDA through MedSun
Participated in quarterly C-Suite meetings with BUMC-P and SQL to report on trends, open lawsuits, claim dollar amounts
Conducted thorough analysis of historical data, helping identify patterns and trends in potential risks.
Presented at CANDOR and Talk2Me in-services to new leadership, residents, and providers across AZ Banner Health entities
Analyzed incident reports to identify trends, facilitating proactive measures to reduce future occurrences.
Worked closely with HIMS and pathology to release records and/or specimens to patients or attorneys
Collaborated with stakeholders to design training programs that promote a culture of safety and accountability.
Developed and implemented risk management strategies to enhance patient safety and operational efficiency.
Trained employees on risk management best practices, empowering them to make informed decisions regarding potential risks.
Conducted comprehensive risk assessments to identify vulnerabilities in clinical and administrative processes.
Utilization Management RN, Supervisor and Subject Matter Expert of team
UnitedHealth Group
01.2012 - 06.2019
Performed prior authorization review of services requiring notification.
Evaluated medical guidelines and benefit coverage to determine appropriateness of services.
Provided clinical claim review for prospective (and prior-auth), concurrent and retrospective reviews including appeals
Reviewed cases for efficacy, medical necessity and appropriateness of care.
Worked UM for behavioral health for appropriate care and/or facility
Used MCG and InterQual for medical necessity reviews
Reviewed for fraud, waste and abuse, especially in regards to Medicare and Medicaid
Review of Diagnosis-Related Groups (DRGs) to control costs. Concurrent reviews to manage inpatient and observation status and progress toward discharge.
Reviewed submitted UB-04 or HCFA-1500 claims for proper coding in billing, including ICD-10-CM, CPT, HCPCS codes
Reviewed Revenue codes for Medicare and Medicaid claims (CMS) to ensure compliance
Used evidence-based guidelines for cost containment. On commercial insurance this would be plan coverage/benefits, NCD, LCD and InterQual
Supervisor responsibilities included working escalations, Dept of Insurance complaints, provider issues and contract disputes
Facilitated workgroup meetings with medical personnel to find effective solutions to issues.
Supervisor responsibilities to my team of 14 RNs and 7 admins included downward management of quality and compliance audits. Audited time and attendance, productivity, monthly scorecards, managing Turn-Around-Time, managing inventory and assigning mandatory and voluntary overtime hours.
SME responsibilities to team included providing resources, input, learning opportunities and coaching for all team members
Ensured compliance with regulations and accreditation standards by maintaining accurate documentation of all utilization review activities.
Contributed to organizational success by providing expert advice on medical necessity criteria and evidence-based practices in utilization review nursing.
Submitted cases for criteria failures and helped facilitate resolutions and approvals.
Obtained authorizations from multiple insurance carriers for various levels of care.
Optimized hospital stays by monitoring admissions for appropriateness based on established clinical guidelines while considering each patient''s unique circumstances.
Enhanced team efficiency with development of streamlined review processes.
RN
Manor Care Skilled Nursing Facility
01.2015 - 01.2019
Administered medication and treatments according to physician orders and established protocols.
Administered medications via oral, IV, and intramuscular injections and monitored responses.
Educated patients, families and caregivers on diagnosis and prognosis, treatment options, disease process, and management and lifestyle options.
Developed strong relationships with patients'' families, providing emotional support while addressing concerns or questions about care plans.
Educated patients on disease management and self-care techniques, promoting lifestyle changes for improved health.
Served as a liaison between physicians and patients'' families to facilitate clear communication regarding treatment options and progress updates.
Devised individualized care plans tailored to each patient''s unique situation, optimizing clinical outcomes.
Utilized advanced clinical skills such as wound care management or IV therapy administration, leading to faster recovery times for patients treated under my supervision.
Streamlined documentation processes to ensure accurate record-keeping and compliance with regulatory standards.
Managed patients recovering from medical or surgical procedures.
Medical Underwriter
UnitedHealth Group
02.2010 - 01.2012
Responsible for medical underwriting, including risk adjustment/scoring for pricing and coding to project future spend for both small groups and large ASO (administrative services only) groups.
Wrote request for proposal (RFP) responses.
Streamlined application review processes through effective organization techniques, reducing turnaround times for prospective clients.
Evaluated medical histories to assess risk for underwriting decisions.
Collaborated with healthcare providers to gather additional information and clarify medical conditions.
Analyzed complex cases, integrating clinical data with underwriting guidelines.
Practiced discretion when handling sensitive personal health information, adhering to strict privacy and confidentiality policies as required by law and company guidelines.
Collaborated with sales teams to ensure timely processing of applications, maintaining high levels of customer satisfaction.
RN Charge, Labor & Delivery
UnityPoint Health
05.2006 - 01.2010
Worked as charge RN in Labor & Delivery, triage, LDRP, L&D OR.
Responsible for ensuring compliance to hospital policy and procedure following ACOG guidelines.
Responsible for staffing needs for following shift, knowing when to utilize on-call RN if needed or having RN stay home in on-call status if unit not busy enough at the time.
Responsible for patient/provider relations and patient care in all areas of the unit.
Collaborated with physicians to quickly assess patients and deliver appropriate treatment while managing rapidly changing conditions.
Improved patient outcomes by providing high-quality nursing care and implementing evidence-based practices.
Trained new nurses in proper techniques, care standards, operational procedures, and safety protocols.
Provided emotional support to patients during challenging times, fostering a sense of trust and rapport that contributed to better overall wellbeing.
Provided direct patient care, stabilized patients, and determined next course of action.
Explained course of care and medication side effects to patients and caregivers in easy-to-understand terms.
Provided skilled, timely and level-headed emergency response to critically-ill patients.
RN Staff Nurse, Labor & Delivery
Bronson Methodist Hospital
10.1991 - 10.2001
Worked as Labor & Delivery staff RN.
Worked in all areas including triage, antepartum, L&D, postpartum and newborn nursery.
Taught Childbirth preparation courses for prospective parents.
Conducted comprehensive patient assessments, identifying critical changes in condition promptly.
Enhanced patient satisfaction through effective communication, empathy, and timely response to their needs.
Explained course of care and medication side effects to patients and caregivers in easy-to-understand terms.
Collaborated with physicians to quickly assess patients and deliver appropriate treatment while managing rapidly changing conditions.
Education
BSN - Healthcare Administration
University of St. Francis
Joliet, IL
01.2000
Certified Professional - Healthcare Risk Management
Phoenix, AZ
01.2020
Diploma - Nursing
Western Michigan University
Kalamazoo, MI
01.1991
Accomplishments
Supervised team of 21 staff members.
Used Microsoft Excel to develop inventory tracking spreadsheets.
Spearheaded and Collaborated with a diverse team in the development of Special Needs Initiative for UHC, providing additional assistance to families identified as having a child/children with identified diagnoses codes related to special needs (autism, down syndrome, etc).
Affiliations
ASHRM: American Society of Healthcare Risk Managers
AzHRM: Arizona Society of Healthcare Risk Managers
AAPC: Arizona chapter
Certification
Certified Profession in Healthcare Risk Management (AHA)
Compact State Licensed RN, BSN
Timeline
Clinical review/UM RN
Cohere Health
10.2024 - 02.2025
Clinical Appeals RN
Aerotek Scientific
06.2024 - 10.2024
Clinical Risk Manager
Banner-University Medical Center Phoenix
06.2019 - 11.2023
RN
Manor Care Skilled Nursing Facility
01.2015 - 01.2019
Utilization Management RN, Supervisor and Subject Matter Expert of team
UnitedHealth Group
01.2012 - 06.2019
Medical Underwriter
UnitedHealth Group
02.2010 - 01.2012
RN Charge, Labor & Delivery
UnityPoint Health
05.2006 - 01.2010
RN Staff Nurse, Labor & Delivery
Bronson Methodist Hospital
10.1991 - 10.2001
Certified Professional - Healthcare Risk Management
