Open To Work
Kareen Blanchard
Thomasville,GA
Summary
Dynamic nurse consultant with a strong foundation in clinical review and regulatory compliance, poised to excel in challenging environments. Results-driven professional recognized for consistently exceeding targets and fostering team collaboration to achieve impactful outcomes. Extensive experience in case review, leveraging expertise in medical documentation analysis guided by Medicare criteria, Clinical Policy Bulletins, and Milliman Care Guidelines. Known for adaptability and a commitment to process improvement, ensuring high standards of care and compliance are met even amidst evolving circumstances.
Overview
24
24
years of professional experience
1
1
Certification
Work History
UM Nurse Consultant
Aetna (CVS Health)
06.2014 - 12.2024
- Utilize Medicare, Aetna Clinical Policy Bulletin and Milliman guidelines to determine medical necessity for prior authorizations for procedures, durable medical equipment, admissions, and inpatient stays both acute and post-acute.
- Work with Medical Directors to determine the medical necessity of requests that need secondary review.
- Worked with Medicare, Medicaid, and Commercial lines of business.
- Monitor and evaluate options to facilitate appropriate healthcare services/benefits for members.
- Gather clinical information and applies the appropriate clinical criteria/guideline, policy, procedure and clinical judgment to render coverage determination/recommendation along the continuum of care.
- Communicate with providers and other parties to facilitate care/treatment.
- Identify opportunities to promote quality effectiveness of Healthcare Services and benefit utilization.
- Consult and lend expertise to other internal and external constituents on the coordination and administration of the utilization/benefit management function.
Pre-Authorization Nurse
Premier Staffing Services for Coventry Health
03.2013 - 06.2014
- Utilize Interqual guidelines to determine medical necessity for prior authorizations for procedures, durable medical equipment, admissions, and other requests.
- Work with Medical Directors to determine the medical necessity of requests that need secondary review.
- Work with Medicare, Medicaid, and Commercial lines of business.
- On a contract
Medical Review Nurse
IntegriGuard
09.2009 - 03.2013
- Employed as a Medical Review Nurse.
- Utilized clinical skills to protect the Medicare trust fund.
- Performed clinical reviews of medical records and/or other documentation to determine the accuracy and appropriateness of billings for provided services such as Part B, home health and durable medical equipment claims.
- Completed medical review report to document findings.
- Maintain internal quality control processes to assure the reliability of projected reviews.
- Provide support to internal and external customers with respect to clinical and Medicare-related issues.
- Conduct claims research using the appropriate systems.
- Conference with the Investigative team as necessary to discuss medical records, provider interviews, research policy, regulations, and coverage determinations.
RN Triage Nurse
Nurse Response-Centene Corporation
08.2008 - 06.2009
- Provide after-hours telephonic triage, care advice, and education to pediatric and adult patients utilizing algorithms, standard-care guidelines, and nursing judgment.
- Assist RN in selecting appropriate algorithm based on patient’s symptoms.
- Provide patient education to parent/patient for self/home care or refer to ER when necessary.
- Lead RN on occasion to registered nurses and customer service representatives.
- Active participation in peer review for quality assurance; and mentor new employee.
RN Care Manager
Care Guide
10.2007 - 08.2008
- Managed care of members in the top one percent of Medicare population to ensure that members stay out of the hospital.
- Provided telephonic holistic management of members.
- Liaison with Physicians and other Providers along with family to provide the best possible care of members.
- Used ICD 9 codes to code diagnoses.
- Used Internet as resources along with Senior Services in the state the member lives to provide community resources to members.
- Assisted members with transportation, prescriptions, and helped member in any way possible to facilitate care.
RN Concurrent Review Nurse
Agency with CSI for WellCare
09.2007 - 10.2007
- Reviewed claims/ cases for continued stay in hospital for members using the Interqual guidelines.
- Worked with hospital reviewers and Case managers to coordinate discharge planning.
- Referred to other disciplines for cases that required Case Management, for example, Behavioral Health.
- Worked with the Medical Director on cases.
- Conducted conferences discussing cases with the team including the Medical Director weekly.
- Contract Assignment
RN Case Manager
GENEX Services, Inc.
10.2006 - 07.2007
- Assessment of workers' compensation, long-term and short-term disability claimants doing onsite visits.
- Assessment of medical case management activities following Florida Managed Care Laws.
RN Case Manager
Seminole Tribe of Florida
03.2003 - 10.2006
- Worked as the first and only Case Manager for the entire Seminole Tribe of Florida on the three reservations with travel to each.
- Followed complex and high-cost cases.
- Monitored frequent admits to the hospital, visited patients in the hospital, and obtained clinical information from the patient's chart.
- Worked closely with the case managers and the hospitals and initiated/facilitated discharge planning.
- Liaison for the family and the health care team
- Home visits for patients that were admitted to the hospital, the elderly, the non-compliant and high cost and complex cases.
- Ordered and monitored medical equipment and other duties as assigned.
Registered Nurse
Coral Springs Medical Center
02.2002 - 03.2003
- Offered direct care to medical-surgical and telemetry patients in a 200-bed hospital.
- Administered patient medication/dosage and interpreted physician instructions.
- Carefully monitored and promptly treated medical-surgical complications and emergencies related to conditions including pain management, infection, nausea, and vomiting.
- Monitored patients on the telemetry floor.
Clinical Nurse Reviewer
All Medical Personnel Agency
06.2001 - 03.2003
- Worked on an as-needed basis with the agency doing various reviews including, workers' compensation, and Hedis review for Well Care HMO, which included a lot of travelling to different doctor locations utilizing HEDIS guidelines for chart audits.
Education
Bachelor of Science Degree - Nursing
06.1991
Skills
- Interprofessional collaboration
- Case documentation
- Clinical expertise
- Medical documentation
Certification
- Registered Nurse in Georgia (Compact License)
- CCM (Certified Case Manager)
Timeline
UM Nurse Consultant
Aetna (CVS Health)
06.2014 - 12.2024
Pre-Authorization Nurse
Premier Staffing Services for Coventry Health
03.2013 - 06.2014
Medical Review Nurse
IntegriGuard
09.2009 - 03.2013
RN Triage Nurse
Nurse Response-Centene Corporation
08.2008 - 06.2009
RN Care Manager
Care Guide
10.2007 - 08.2008
RN Concurrent Review Nurse
Agency with CSI for WellCare
09.2007 - 10.2007
RN Case Manager
GENEX Services, Inc.
10.2006 - 07.2007
RN Case Manager
Seminole Tribe of Florida
03.2003 - 10.2006
Registered Nurse
Coral Springs Medical Center
02.2002 - 03.2003
Clinical Nurse Reviewer
All Medical Personnel Agency
06.2001 - 03.2003