Kimberly Girten
Registered Nurse
Newark,DE
Summary
Well-qualified Nurse Consultant bringing 10 years of medical care and case review experience. Offering in-depth understanding of medical case review, natural interpersonal strengths and technical abilities. Quality-focused and efficient team player, skilled at multitasking and prioritization.
Overview
16
16
years of professional experience
3
3
Certification
Work History
Appeals Nurse Consultant
Aetna
07.2019 - Current
- Serve as liaison between insured members and health care providers, by providing a continuum of care
- Encourage members to take action regarding their health, in order to minimizing healthcare costs and enhance health care efficiencies
- Educate insured members on important health issues regarding cholesterol, blood pressure, and oral diabetic medications, and importance of medication adherence
- Use multiple web-based applications while assisting insured with health and medical issues
- Utilize excellent communication skills, and my ability to multitask and effectively problem solve in a high demanding environment.
- Performed prior authorization review of services requiring notification.
- Reviewed and prepped cases to appropriate medical doctors for medical necessity review
- Evaluated medical guidelines and benefit coverage to determine appropriateness of services.
- Performed reviews of member and provider cases based for medical necessity and/or benefit guidelines
Appeals Nurse Consultant
Aetna
05.2018 - 07.2021
- Utilizes clinical skills and apply critical thinking and knowledge when appropriate treatment, evidence-based care and medical necessity criteria for appropriate utilization of services
- Gathers clinical information and applies the appropriate medical necessity criteria/guideline, policy, procedure and clinical judgment to render coverage determination/recommendation/discharge planning along the continuum of care
- Utilizes clinical experience and skills in a collaborative process to evaluate and facilitate appropriate healthcare services/benefits for members and provider appeals
- Coordinates/Communicates with providers and other parties to facilitate optimal care/treatment
- Consults as a panel member since September 2021
- Expedited member appeals that have 24-72 hour turnaround time once every 5 weeks and twice a year weekend rotation
- Assist with Member panel hearings appeals as a panel member since
- August 15, 2023 with cross trained Behavioral Health member and provider appeals
- September 12, 2023 began serving as a panel member for formal and informal panel hearings
Case Manager
Aetna
03.2013 - 04.2018
- Healthy Outcome Team, assisted clients in finding new ways to inspire healthier habits.
- Maintained records of clients' health progress and compared to health goals.
- Educated patients on health action plans and bridged gaps and provided resources with medication refills
- Recommended nutrition and fitness modifications to improve overall health of clients.
- Assisted project with switching patient's to Aetna's 90-day mail order delivery service
- Supported implementation of patient health plan, weight loss programs and personalized fitness and exercise programs and sleep program
RN
Bayada
01.2009 - 12.2009
- Provided specialized nursing care to pediatrics, with various specialized needs, to maintain a safe home life with comfort, independence, and dignity, despite illness or disability
- In charge of the direct care of pediatrics restricted to home care setting
- Aided in maintenance and improvement of patient's quality of life
- Ability to handle multiple tasks with minimal guidance
- Committed to safe, high-quality home health care, delivered with compassion, excellence, and reliability.
ER RN
Christiana Care
04.2007 - 04.2009
- As part of a Level I Trauma Center, provided care to the most severely injured of all ages in the area, treating patients with a wide range of illnesses and injuries
- Provided comprehensive care for infants, children, adolescents, alongside adults with cardiac, thoracic and vascular diseases in a high-volume, fast-paced environment
- In this non-stop busy setting, remained well-organized, focused, and committed to quality patient care that emphasized the patient first.
Education
Bachelor's Degree - Behavioral Science
Wilmington University
06.2012
Associate's Degree - Nursing
Cecil Community College
05.2007
Skills
- Case Documentation analysis
- Accurate Documentation
- Records Review
- Microsoft Office
Certification
Level of Care Utilization System for Psychiatric and Addictive Services (LOCUS) Basic Training
Child and Adolescent Level of Care Utilization System (CALOCUS)
American Society of Addiction Medicine (ASAM)
Languages
English
Technology Experiences
- Desktop Tools, Microsoft Foundation Classes, Intermediate - Power user
- Desktop Tools, TE Microsoft Excel, Intermediate - Power user
- Desktop Tools, Microsoft PowerPoint, Intermediate - Power user
- Desktop Tools, Microsoft Word, Advanced - Admin/support
- Multimedia, Adobe Photoshop, Basic - End user
- Aetna Applications, ATV Reporting, Basic - End user
- Aetna Applications, LaunchASD, Basic - End user
Web-based applications
IOP, Encoder, ASD (PegaReach), Rumba, MedHok, Client Care Access (CCA), ATV, MedCompass, DocFind, ePublishing, Flash Code, Cotiviti (PPM Claims Inquiry Tool), McKesson Total Payment Solution (TPS), ECHS, CATS, Novologix, EviCore, CareCore, MCG, MCD, External Vendors: MCMC, Peer Point AllMed, IMEDECS, MRIoA and PREST
Timeline
Appeals Nurse Consultant
Aetna
07.2019 - Current
Appeals Nurse Consultant
Aetna
05.2018 - 07.2021
Case Manager
Aetna
03.2013 - 04.2018
RN
Bayada
01.2009 - 12.2009
ER RN
Christiana Care
04.2007 - 04.2009
Bachelor's Degree - Behavioral Science
Wilmington University
Associate's Degree - Nursing
Cecil Community College
Nursing/Registered Nurse (Certified), RNC, 08/01/2007
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