KRISTEN LEAL
Bastrop,TX
Summary
Dedicated and compassionate Registered Nurse (RN) with progressive career history in Clinical Utilization Management, Clinical Letter Writing Management and Recovery Cycle Management. Proven ability to remain calm under pressure and skillfully handle challenges and high-stress situations. Develops strong relationships within the Clinical Team, collaborating with internal departments through professional communication, a respectful attitude, and an excellent work ethic. Strong leader and problem-solver dedicated to streamlining operations to decrease costs and promote organizational efficiency.
Overview
12
12
years of professional experience
1
1
Certification
Work History
RN, Clinical Appeals Supervisor
R1 Rcm
Chicago, IL
01.2025 - Current
- Management of a team of 28 clinical and coding appeals nurses, who write payor appeal letters on behalf of client facilities.
- Monitoring of client inventory to facilitate the meeting of SLAs.
- Collaborated with other departments to coordinate workflow processes between teams.
- Developed strategies to improve team performance and productivity.
- Monitored employee productivity levels on a regular basis to identify areas of improvement.
- Maintained accurate records of employee performance, attendance, leave requests, and disciplinary actions.
- Managed scheduling for staff, ensuring adequate coverage during peak times and projects.
- Coordinated with other department supervisors to ensure smooth workflow and project alignment.
- Prepared and presented reports on team performance, challenges, and achievements to senior management.
- Led weekly team meetings to discuss progress, address issues, and plan future actions.
- Maintained positive working relationship with fellow staff and management.
Clinical Manager, Utilization Management
Integra Partners, LLC
Detroit, MI
12.2024 - Current
- Managed a staff of seven prior authorization clinicians and provided periodic performance evaluations.
- Managed daily operations, including staffing levels, budgeting, scheduling, and resource allocation.
- Developed and maintained clinical policies and procedures.
- Provided oversight of compliance with all federal, state, local regulations, laws, and standards.
- Monitored the performance of clinical staff against established metrics.
- Coordinated interdisciplinary teams for complex cases.
- Ensured that staff members adhered to professional standards of practice.
- Assisted with recruitment, selection, orientation, and training activities for new employees.
- Participated in meetings with other healthcare professionals to discuss best practices.
- Implemented strategies for improving efficiency within the department.
- Analyzed data to identify trends in quality improvement initiatives.
- Encouraged high morale and staff retention through effective communication, prompt problem resolution, proactive supervisory practices, and facilitation of a proactive work environment.
- Employed active listening and interpersonal talents to effectively interact with various individuals, including physicians, patients, and fellow employees.
- Developed and initiated departmental goals, standards of performance, policies, and procedures.
- Interviewed applicants and made recommendations for new hires.
- Improved policies and procedures through the development, implementation, revision, and evaluation of new protocols.
- Enforced compliance with local, state, and federal healthcare regulations, including Medicare and Medicaid requirements, and HIPAA.
- Delegated tasks to each member of staff and oversaw task completion, offering assistance to promote success.
- Introduced new departmental policies, and oriented staff to facilitate the adoption of changes.
- Evaluated quality index scores and key performance indicators to identify opportunities for improvement.
- Implemented a highly effective onboarding and coaching program for new and existing staff members and promoted cross-training in other areas.
- Oversaw clinical operations and procedures while remaining current on federal and state regulations to ensure organizational processes were fully compliant with new healthcare law requirements.
- Devised training programs to close gaps in nurses' and staff's competencies.
- Employed data security methods to keep patient information confidential when reviewing clinic records.
Clinical Letter Writing Manager, RN
Evolent Health
Arlington, VA
06.2013 - 06.2023
- Managing a staff of 11 (8 nurses and 3 non-clinical staff) to ensure notifications go out to members and providers timely
- Monitoring of staff productivity, quality, adherence to company policies and procedures, and attendance
- Attend client-facing and internal meetings
- Approval of timesheets, time off requests, and expenses
- Updating of internal work instructions and resource materials
- Training of new staff to ensure NCQA/URAC, writing techniques, grammatical, and timeliness requirements are met for all notifications
- Coordination of time-off schedules and ensuring staffing needs are met
- Lead on implementation of new, client-facing notification documents for UM and appeal letters as required
- Weekly team and bi-weekly individual meetings with staff
- Reviewing adverse determinations against criteria and medical policies
- Quality assurance of prior authorization cases/processes as part of the process of generating a notification to members and providers
- Working with physician reviewers to monitor the adverse determination process and ensure notification timeframes are met
- Creates adverse determination notifications that meet all accreditation, State, and Federal criteria
- Use of plain language and excellent written skills to clearly communicate adverse decisions to both members and providers
- Working with internal and external staff to ensure that decisions are made, documented and communicated clearly
- Appropriately identifying and referring quality issues to the Senior Director of Medical Management or Medical Director
- Professionally communicates appropriate information to other staff members and departments as necessary/required
- Participates in continuing education initiatives and other internal learning opportunities
- Collaborates with Human Resources, Claims, Quality Management, Appeals, Licensing, Compliance and Provider Relations Departments as required.
- Coached, mentored and trained team members in order to improve their job performance.
- Conducted regular meetings with staff to discuss progress and identify areas of improvement.
- Established processes to ensure efficient workflow throughout the organization.
- Provided leadership during times of organizational change or crisis situations.
- Assessed team member's skillsets and assigned tasks accordingly for optimal efficiency.
- Collaborated with other departments to ensure timely completion of projects within budget constraints.
- Ensured compliance with all applicable laws, regulations, industry standards.
- Monitored staff performance and addressed issues.
- Exercised good judgment and decision-making in escalating concerns and resolving issues.
- Completed thorough opening, closing and shift change functions to maintain operational standards each day.
- Assigned tasks to associates to fit skill levels and maximize team performance.
- Recruited and hired qualified candidates to fill open positions.
- Enhanced team member performance through use of strategic and tactical approaches, motivational coaching and training.
- Led team meetings and one-on-one coaching sessions to continuously improve performance.
- Leveraged leadership skills to identify deficiencies and opportunities to improve policies, procedures and controls.
- Communicated company directives and programs to associates and ensured all follow-up items were completed accurately and timely.
- Maintained adequate staffing to meet objectives within budget.
- Minimized staff turnover through appropriate selection, orientation and training.
- Created training modules and documentation to train staff.
- Delegated work to staff, setting priorities and goals.
- Provided leadership, insight and mentoring to newly hired employees to supply knowledge of various company programs.
- Recruited and trained new employees to meet job requirements.
- Reviewed completed work to verify consistency, quality and conformance.
- Reviewed employee performance and provided ongoing feedback and coaching to drive performance improvement.
- Interviewed prospective employees and provided input to HR on hiring decisions.
- Planned and led team meetings to review business results and communicate new and ongoing priorities.
- Maintained accurate documentation of patient records in accordance with HIPAA regulations.
Education
Associate of Applied Science: Registered Nurse -
Austin Community College
Austin, TXSkills
- Instructional Materials Development
- Resource Monitoring
- HIPAA Guidelines
- Electronic Health Records Systems
- Process Evaluations
- Staff Training
- Clinical Quality Program Standards
- Nurse Collaboration
- Team Mentorship
- Set Objectives
- Utilization Management
- Quality Assurance Controls
- Operational Standards
- Clinical Documentation Management
- Author Reports
- Recruit Well-Qualified Staff
- Developing training programs
- Training and mentoring
- Staff Supervision
- Team Meetings
- Regulatory Compliance
- HIPAA
- Supervisory Experience
- Team Management
- Onboarding and coaching
- Compliance with regulatory guidelines
- Compliance Oversight
- Effective Communication
- Managerial experience
Certification
06/2002, Licensed Registered Nurse, TX, 687039
References
References available upon request.
Timeline
RN, Clinical Appeals Supervisor
R1 Rcm
01.2025 - Current
Clinical Manager, Utilization Management
Integra Partners, LLC
12.2024 - Current
Clinical Letter Writing Manager, RN
Evolent Health
06.2013 - 06.2023
Associate of Applied Science: Registered Nurse -
Austin Community College
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