KIMBERLY GIRTEN

• 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 appropriate medical necessity criteria/guideline, policy, procedure and clinical judgment to render coverage determination/recommendation/discharge planning along continuum of care

• Utilizes clinical experience and skills in collaborative process to evaluate and facilitate appropriate healthcare services/benefits for members and provider appeals

• Performed prior authorization review of services Expedited member appeals that have 24-72 hour turnaround time once every 5 weeks and weekend rotation twice/year

Special project: Medicare provider appeals November 2022 - February 2023

• Member Appeal Panel hearings September 2021 to current

• Behavioral Health Panel hearings for Member appeals since September 12, 2023 to current

• Behavioral Health member and provider appeals from August 15, 2023 to current

• Medicare Per Diem on weekends February 2020 to June 2020 and June 2022 to August 2024

• Assisted with Medicare coding reconsideration appeals August 2020 to October 2020

• Evaluated medical guidelines and benefit coverage to determine appropriateness of services.
• Assisted clients in finding new ways to inspire healthier habits.

• Educated patients on health action plans and assisted with bridging gaps, providing resources for medication refills to promote positive healthy habits and wellbeing

• Educate members on important health issues regarding cholesterol, blood pressure, and oral diabetic medications, and importance of medication adherence.

• Recommended nutrition and fitness modifications to improve overall health of clients.

• Assisted on special project assisting members steerage to Aetna 90-day mail order delivery service

• Supported implementation of patient health plan, weight loss programs, exercise programs, disease management and sleep program

• Coordinated services healthcare professionals to provide useful benefits to clients • Evaluated treatment plans against individual goals and healthcare standards

• Provided education on health and nutrition for patients

• Provided specialized nursing care to pediatrics, with various specialized needs, to maintain safe home life with comfort, independence, and dignity
• In charge of direct care of pediatrics with tracheostomy and ventilator restricted to home care setting
• Committed to safe, high-quality home health care, delivered with compassion, excellence, and reliability.
• Provided physical assessments, medication, and chronic disease management to home health patients.
• Administered medications and treatments as prescribed by physicians.
• Monitored vital signs, developed and implemented care plans, and documented patient progress.
• Determined and addresses individual home care needs by completing detailed assessments and reviewing documentation.
• Provided exceptional care to high-acute patients needing complex care such as ventilator management, extensive wound care and rehabilitation.

• Level 1 Trauma Center, provided care to patients all ages, treating patients with wide range of illnesses and injuries Provided comprehensive care for infants, children, adolescents, alongside adults with cardiac, thoracic and vascular diseases in high-volume, fast-paced environment
• In this non-stop busy setting, remained well-organized, focused, and committed to quality patient care that emphasized patient first.
• Answered codes quickly and orchestrated efficient, skilled medical care teamed on trauma and emergency interventions involving serious head injuries, gunshot wounds, and thoracic trauma
• Monitored vital signs, conducted physical assessments and evaluated laboratory results for strategic care planning
• Delivered high level of quality care to diverse populations while overseeing patient admission and triaging based on acuity and appropriate department admission
• Provided skilled, timely and level-headed emergency response to critically-ill patients
• Performed triage on incoming patients and determined severity of injuries and illnesses
• Communicated with healthcare team members to plan, implement and enhance treatment strategies
• Offered exceptional care and support to individuals recovering from acute incidents and dealing with chronic conditions
• Quickly responded to situations impacting safety and security to unit, actualizing crisis prevention interventions to control and de-escalate situations
• Promoted patient and family comfort during challenging recoveries to enhance healing and eliminate non-compliance problems