Kristen Johnson

• Daily review of member allegations against providers and facilities regarding quality-of-care and quality-of-service concerns.
• Understanding and working knowledge of complex medical treatments and terms.
• Working knowledge of sometimes complex company policies and procedures and state-specific laws and requirements for case reviews.
• Assist Clinical Administrative Coordinators (CACS) to obtain requested grievance responses, medical records, and letters of inquiry response.
• Provide direction to CACs regarding the next steps to take to obtain records when providers are not responding to requests.
• Technological proficiency and ability to navigate Microsoft Teams for calls, meetings, and chat. Ability to effectively use Outlook, Word, Excel, and Adobe Acrobat.
• Navigate our company applications including Facets, ICM, MACESS, Optum Rx, Altruista, Maestro, QCARE, and ICUE.
• Demonstration of excellent written and verbal communication skills as it is necessary to collaborate and communicate with licensed and unlicensed colleagues in the quality-of-care department and other departments, members, facilities, and providers named in allegations.
• Solve complex problems independently while knowing when to seek assistance from senior RNs and management.
• Appropriately level concerns as unsubstantiated, minor, moderate, or severe and review with the medical director as appropriate.
• Accurately document case review findings on case summaries and upload them into the QCARE system.
• Attend and contribute as appropriate to department meetings.
• Collaborated with physicians to quickly assess patients and deliver appropriate treatment while managing rapidly changing conditions
• Follow all personal and health data procedures to effectively comply with HIPAA laws and prevent information breaches

Perform benefit and medical necessity reviews of services requiring prior authorization, and process denials, appeals, and retros.

• Perform clinical medical necessity reviews based on ASAM, MCG, Medicaid Services Manual, and United Healthcare criteria
• Identify and implement solutions for irregular requests and issues
• Managed time efficiently in order to complete all tasks within deadlines
• As part of the Denial Team, collaborated with managers and Quality Assurance to improve NCQA standing from provisional to pass in less than a year
• Retro, appeal, and denial SME
• Research issues and take appropriate action to resolve issues within turnaround time requirements and quality standards
• As part of the PPD Performance Improvement Team, implemented a new process that resulted in improving outreach to mothers with postpartum depression and anxiety
• Effectively communicate with community providers to foster good rapport and relationships and provide any needed education on member benefit plans and exclusions
• Manage stat and crisis calls and make appropriate referrals to ensure our members have access to the services they need or if appropriate, call emergency services and remain on the line with the member until they are safe
• Pull denial universe and bookmark files for NCQA audits and attend NCQA audits
• Facilitated communication between members and various departments and staff.
• Assist UM Manager with various tasks such as maintaining crisis call rotation and being a resource to new hires.
• Adaptable and proficient in learning new concepts quickly and efficiently
• Demonstrated a high level of initiative and creativity while tackling difficult tasks
• Skilled at working independently and collaboratively in a team environment

• Utilize exceptional writing, editing, and proofreading skills to produce engaging and error-free content
• Organize material to research and complete writing tasks
• Writing 900-1000 word articles per client instructions
• Managing competing deadlines with efficiency
• Complete thorough research into assigned topics
• Researching and writing technical articles on psychiatric and substance use disorders for clients

• Facilitated therapeutic communication, conflict resolution, and crisis intervention by redirecting negative behaviors and helping patients regain or improve coping abilities
• Performed ongoing assessments to evaluate mental health needs, working with the multidisciplinary team to develop, initiate, manage, and modify individualized plans of care
• Communicated with healthcare team members to plan, implement and enhance treatment strategies
• Administered medications via oral, SQ, and intramuscular injections, monitoring responses to catch and address new concerns
• Accurately documented treatment, medications and IVs administered, discharge instructions, and follow-up care in Meditech, Sorian, and Epic EHRs
• Observed and reported patient condition, progress, and medication side effects to accurately document updates
• Offered exceptional care and support to individuals with mental illness and substance use disorder
• Supervised MHTs
• Responded to numerous volatile situations and violent outbreaks to restore the safety and security of patients and staff.
• Explained course of care and medication side effects to patients and caregivers in easy-to-understand terms.
• Educated family members and caregivers on patient care instructions.
• Advocated for and strived to protect the health, safety, and rights of patients.

• Served as backup supervisor when needed
• Collaborated with physicians, social workers, activity therapists, nutritionists, and case managers to develop and implement individualized care plans and document all patient interactions and interventions in electronic charting systems
• Collected blood, tissue, and other laboratory specimens and prepared for lab testing
• Observed and reported patient condition, progress, and medication side effects to accurately document updates
• Delivered outstanding care to patients with various diagnoses and managed care from treatment initiation through to completion
• Conducted ongoing monitoring and evaluations of behaviors and conditions, and updated clinical supervisors with current information
• Trained new nurses in proper techniques, care standards, operational procedures, and safety protocols to optimize performance and safety
• Delivered medications via oral, SQ, and intramuscular injections, monitoring responses to catch and address new concerns
• Supervised forensic techs
• Responded to numerous volatile situations and violent outbreaks to restore the safety and security of patients and staff.
• Oversaw care of suicidal patients and acted swiftly to reduce the risk of harm to themselves or others.

• Served as backup night shift supervisor and was promoted to night shift supervisor
• Ensured safe and appropriate staffing of the hospital each night
• Followed all personal and health data procedures to effectively comply with HIPAA laws and prevent information breaches
• Managed care from admission to discharge, including patient assessments, care planning, health education, and discharging support to provide comprehensive care to over 40 patients daily
• Performed ongoing assessments to evaluate mental health needs, working with the multidisciplinary team to develop, initiate, manage, and modify individualized plans of care
• Conducted ongoing monitoring and evaluations of behaviors and conditions, and updated clinical supervisors with current information
• Accurately documented all elements of nursing assessment, including treatment and medications administered, labs, discharge instructions, and follow-up care
• Trained new nurses in proper techniques, care standards, operational procedures, and safety protocols to optimize performance and safety
• Reported findings to quality departments after conducting routine restraint audits and worked with the team to devise corrective actions for deficiencies
• Facilitated therapeutic communication, conflict resolution, and crisis intervention by redirecting negative behaviors and helping patients regain or improve coping abilities to prevent further disability
• Collected blood, tissue, and other laboratory specimens and prepared for lab testing
• Provided skilled, timely, and level-headed emergency responses to patients experiencing medical and behavioral emergencies
• Participated in education activities, including evidence-based practice project implementation, nursing competency development, and nursing simulation activities
• Oversaw care of suicidal patients and acted swiftly to reduce the risk of harm to themselves or others.
• Responded to volatile situations and violent outbreaks to restore the safety, and security of patients and staff.