Summary
Overview
Work History
Education
Skills
Certification
SUMMARY OF QUALIFICATIONS
Timeline
Generic

KAREN WHALEY

Friendsville,TN

Summary

Dedicated and motivated professional with a diverse background in Nursing, Case Management, and Clinical Administration. Years of successful experience communicating effectively with physicians and other medical professionals while providing quality care for diverse patient populations. Consistently recognized for outstanding contributions to towards healthcare objectives and commended for priority management skills.

Smart Utilization Review Nurse considered critical thinker and problem-solver due to dynamic patient care planning and understanding of Medicare guidelines. Known for having great rapport with providers and insurance carriers.

Overview

33
33
years of professional experience
1
1
Certification

Work History

Utilization Review Nurse

Humana
07.2013 - Current
  • Evaluated medical guidelines and benefit coverage to determine appropriateness of services.
  • Supervised and maintained all utilization review documentation.
  • Facilitated workgroup meetings with medical personnel to find effective solutions to issues.
  • Submitted cases for criteria failures and helped facilitate resolutions and approvals.
  • Performed admission reviews based for medical necessity based upon inpatient specification.
  • Followed all personal and health data procedures to effectively comply with HIPAA laws and prevent information breaches.

Registered Nurse (RN) – PeriAnesthesia

BLOUNT MEMORIAL HOSPITAL
01.2011 - 07.2013
  • Advised patients and caregivers of proper wound management, discharge plan objectives, safe medication use, and disease management.
  • Performed triage on incoming patients and determined severity of injuries and illnesses.
  • Managed patients recovering from medical or surgical procedures.
  • Evaluated patient histories, complaints, and current symptoms.
  • Educated family members and caregivers on patient care instructions.

Registered Nurse (RN) – Critical Care

BLOUNT MEMORIAL HOSPITAL
01.2005 - 01.2011
  • Collaborated with leadership to devise initiatives for improving nursing satisfaction, retention and morale.
  • Leveraged feedback and process improvement opportunities to create safer and healthier environment and increase patient satisfaction.
  • Quickly responded to situations impacting safety and security to unit, actualizing crisis prevention interventions to control and de-escalate situations.
  • 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.
  • Performed frequent checks on life support equipment and made necessary adjustments to preserve optimal patient conditions.
  • Implemented care plans for patient treatment after assessing physician medical regimens.

Office Assistant – Case Management

BLOUNT MEMORIAL HOSPITAL
01.1996 - 01.2005
  • Answered and managed incoming and outgoing calls while recording accurate messages for distribution to office staff.
  • Kept office supplies well organized and sufficiently stocked, placing orders promptly to replenish materials before depleted.
  • Informed and supported business leaders through consistent communication and administrative support duties.
  • Promptly received and forwarded incoming communications, such as phone calls, emails, and letters, to appropriate staff.

Secretary

COBIA BOATS
01.1993 - 01.1995
  • Provided clerical support to company employees by copying, faxing, and filing documents.
  • Answered multi-line phone system and enthusiastically greeted callers.
  • Opened and properly distributed incoming mail to promote quicker response to client inquiries.
  • Managed phone and email correspondence and handled incoming and outgoing mail and faxes.

Education

Associate's Degree - Nursing

LINCOLN MEMORIAL UNIVERSITY
Harrogate, TN

Business Concentration

TUSCULUM COLLEGE
Greenville, TN

Skills

  • Nursing & Assisting
  • Patient Assessment
  • Medication Administration
  • Clinical Management
  • Treatment Planning
  • Medical Terminology
  • Charting & Records
  • Insurance Review
  • Emergency Response
  • Physician Relations
  • Home Health Care
  • Case Coordination
  • Physician consultations
  • Communication
  • Inpatient care
  • Utilization management
  • Clinical assessment
  • Discharge planning coordination
  • HIPAA compliance
  • Medicare
  • Utilization review
  • Healthcare regulations

Certification

  • Registered Nurse (RN) - License #0000153099
  • ALS Certified
  • PALS Certified
  • BLS Certified

SUMMARY OF QUALIFICATIONS

  • Responsible for initiating the nursing process and ensuring the optimum level of care for patients
  • Planned and coordinated treatment plans with doctors, technicians, and other medical professionals
  • Evaluated patient needs including physical, psychological, spiritual, cultural, and socio-economic
  • Administered medications and maintained an up-to-date knowledge of pharmaceutical practices
  • Participated in the preparation and implementation of written nursing care plans for patients
  • Consulted with therapeutic multi-disciplinary teams in reviewing patient treatment and progress
  • Updated patient medical files and charts and ensured the accuracy of all clinical documentation
  • Acted as a patient advocate and maintained strict patient confidentiality regarding health issues

Timeline

Utilization Review Nurse

Humana
07.2013 - Current

Registered Nurse (RN) – PeriAnesthesia

BLOUNT MEMORIAL HOSPITAL
01.2011 - 07.2013

Registered Nurse (RN) – Critical Care

BLOUNT MEMORIAL HOSPITAL
01.2005 - 01.2011

Office Assistant – Case Management

BLOUNT MEMORIAL HOSPITAL
01.1996 - 01.2005

Secretary

COBIA BOATS
01.1993 - 01.1995

Business Concentration

TUSCULUM COLLEGE

Associate's Degree - Nursing

LINCOLN MEMORIAL UNIVERSITY

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KAREN WHALEY