Hi, I’m
Kristen Horton
Crossville,TN
Summary
Multi-state Licensed Practical Nurse. Bachelors Degree in Economics. Dedicated and skilled in Utilization Review and Quality Assurance. Promotes cost-effective and quality outcomes for an organization by applying and interpreting the organization's procedure guidelines and policies. Has a strong attention to detail, strong analytical and problem-solving abilities, excellent communication skills, and thorough understanding of quality control processes and methodologies under the Centers for Medicare and Medicaid Services. Authorized to work in the US for any employer
Overview
12
years of professional experience
1
Certification
Work History
The Cigna Group
Quality Review and Audit Lead Analyst
05.2020 - Current
Job overview
- Developed and maintained strong relationships with providers and members.
- Planned, developed, and coordinated cost-effective department operations to meet current and future business needs within organization.
- Coordinated and supported auditing of data related to CMS processes.
- Identified potential fraud risks through thorough analysis of financial data and documentation.
- Evaluated the effectiveness of implemented solutions post-audit, ensuring ongoing compliance with recommendations.
- Streamlined internal processes for improved medical reporting and reduced errors.
- Served as a trusted advisor to senior management on matters relating to internal controls, risk management, and governance.
- Contributed to increased transparency by communicating audit findings clearly to management teams.
- Improved audit quality by providing ongoing training and support to junior audit staff members.
- Performed in-depth reviews of organizational systems, identifying opportunities for process improvement and cost savings.
- Conducted comprehensive audits, ensuring compliance with regulatory standards and company policies.
- Assisted in the successful completion of external audits through timely provision of required information and documentation.
- Partnered with auditors to track errors and add contributions to maintain accuracy.
- Identified and resolved problems through root cause analysis and research.
- Maintained up-to-date knowledge on industry trends, legislation changes, and best practices related to auditing standards.
- Contributed to the development of clinical pathways for common medical conditions, ensuring a standard approach to care was consistently applied across all units within the organization.
- Facilitated interdisciplinary collaboration for the development and implementation of evidence-based practice guidelines, promoting consistency in patient care delivery.
- Served as a subject matter expert on best practices in nursing care delivery during accreditation visits from external agencies, securing ongoing recognition of the department''s commitment to quality.
- Advocated for a culture of transparency surrounding quality assurance findings, fostering accountability among all levels of staff members within the organization.
- Evaluated nursing competencies through regular assessments, identifying areas for professional growth and development opportunities.
- Streamlined communication between healthcare professionals by implementing efficient reporting systems for quality assurance findings.
- Reviewed medical records to ensure accuracy and completeness, leading to more effective care coordination among healthcare providers.
- Documented treatments delivered, medications and IVs administered, discharge instructions, and follow-up care.
- Followed all personal and health data procedures to effectively comply with HIPAA laws and prevent information breaches.
Cigna
Case Management Analyst
07.2019 - Current
Job overview
- Performed prospective, retrospective and concurrent utilization reviews per specified state and national guidelines
- Able to successfully navigate CMS guidelines and regulations to ensure medical necessity founded for authorization requests
- Hand picked by supervisor to transition to audit review team
- Developed and maintained effective personal relationships with members and medical providers
- Demonstrated excellent communication skills to ensure customer satisfaction and retention to produce results-oriented service.
Huron County Medical Care Facility
Licensed Practical Nurse
01.2018 - 05.2019
Job overview
- Worked in the rehabilitation center administering medications and communicating with physicians
- Passed medications, dressed wounds and developed care plans
- Worked side by side with PT and OT to ensure patients were able to be safely discharged back to their home environments.
SCHEURER HOSPITAL
Certified Senior Pharmacy Technician
11.2015 - 03.2017
Job overview
- Was a team member in the outpatient clinic where I was responsible for creating schedules, maintaining inventory, handling customer issues, and counting/filling prescriptions
- I coordinated with physicians in regard to appropriate patient care and implemented protocol
- Kept record of all medications.
WALGREENS PHARMACY
Certified Senior Pharmacy Technician
05.2012 - 11.2015
Job overview
- Senior Pharmacy Technician as well as Tech-Check-Tech where I coordinated with other team members to run a safe and effective pharmacy
- Certified to check and process patient prescriptions when Pharmacist was not available to do so
- I ordered all medications and implemented return protocol.
Education
SAINT CLAIR COUNTY COMMUNITY COLLEGEPort Huron, MI
PN certificate in Nursing
12.2017
OAKLAND UNIVERSITYAuburn Hills, MI
Bachelor Of Science In Economics, Minor In Finance
05.2011
Skills
- Utilization Review
- Quality Assurance
- Documentation Review
- Medical Records
- Caring for and assisting patients with activities of daily living
- Dressing applications and wound care
- Patient and family education
- Medication administration
- Assessing vital signs
- Proper documentation
- Strategic Thinking
- Coaching and Mentoring
- Data Analytics
- Audit Planning
- Analytical mindset
- Results-Oriented
- Patient Care
- Medication and IV administration
- Direct Patient Care
- Patient Assessment
- Clinical Documentation
- Patient Education
- Clinical judgment
- Healthcare ethics
- Care plan implementation
- Nursing staff leadership
- Disease Prevention
- Community health
- Team Coordination
- Complex Problem-Solving
- Strong Clinical Judgment
- High level of autonomy
- Medical Recordkeeping
- Primary Care Experience
- Microsoft Excel
- Training
- Data Entry
- Management
- Microsoft Office
- Time Management
- Management Experience
- Problem solving
- Case Management
- Experience Administering Injections
- EMR Systems
- Epic
- Medication Administration
- Pharmacy Technician Experience
Certification
PN, 05/01/25, TN
Personal Information
Title: Nurse
Timeline
Quality Review and Audit Lead Analyst
The Cigna Group
05.2020 - Current
Case Management Analyst
Cigna
07.2019 - Current
Licensed Practical Nurse
Huron County Medical Care Facility
01.2018 - 05.2019
Certified Senior Pharmacy Technician
SCHEURER HOSPITAL
11.2015 - 03.2017
Certified Senior Pharmacy Technician
WALGREENS PHARMACY
05.2012 - 11.2015
SAINT CLAIR COUNTY COMMUNITY COLLEGE
PN certificate in Nursing
OAKLAND UNIVERSITY
Bachelor Of Science In Economics, Minor In Finance
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