LaVona Edwards
Hamden,CT
Summary
Experienced Registered Nurse with 12 years of nursing experience in various nursing environments including acute care, Remote, operating room, home care, and managed care, and remote environments. Skilled at assessing medical necessity, level of services, and evaluating the appropriateness and quality of care. Successful at promptly demonstrating analytical problem-solving to make decisions and resolve conflict regarding submitted medical documentation. Adept at organizing work to effectively prioritize increased and more complex workloads. Adept at working in matrix environment within major insurance corporation.
Overview
14
14
years of professional experience
1
1
Certification
Work History
Clinical Quality RN-National Audit Team
United Health Group
01.2022 - Current
- Reviews and audits medical documentation/charts and records
- Assists with report preparation and records regarding work function activities and projects
- Coordinates quality management and Special Needs Plans Models of Care(SNPMOC)related programs and activities as required
- Supports quality improvement programs
- Participates in and represents the Clinical Quality Team by collaborating with internal business partners focusing on quality improvement
- Participates in or coordinates with other department projects as needed.
RN Clinical Quality Assurance Oversight HEDIS Specialist (CQO)
United Health Group
12.2017 - 12.2021
- Responsible for successful clinical quality audit season of over 800 specialty exclusion charts in first year of being promoted to head of exclusionary charts department
- Original member of department formed to correct company’s tract record of failing quality audits
- All quality audits passed since hire in 2017
- Participates in verifying the accuracy of and training on the process for abstracting tens of thousands of medical records successfully ensuring that quality assurance standards are met while identifying issues and working with the team to close gaps and promptly return to levels of acceptability
- Trusted by management to administer written and verbal education to 40 less experienced team members to ensure accurate understanding of policies and procedures
- Functions as a junior subject matter expert in highest capacity as a Clinical Quality Oversight Nurse (CQO)
- Completes and processes 5-40 medical chart review audits daily, continually applying medical knowledge in reviewing and analyzing patient records from multiple health plan companies entering data in the appropriate computer system while adhering to pressing deadlines while simultaneously applying NCQA guidelines for quality of care standards
- Remains current with medical codes, claims, and terminology acting as a liaison between physicians, patients, and insurance companies to ensure understanding of required documentation to meet quality of care standard requirements.
Registered Nurse
Yale New Haven Hospital
06.2013 - 06.2015
- Assessed, planned, and coordinated care for medical surgical and operating room patients based on individual needs and specific physician orders
- Helped to decrease adverse surgical events by performing and coordinating operating room audits with doctors
- Taught effective method to prevent the need for repeat surgery due to technician and nurse error
- Monitored to ensure targeted changes and appropriate corrective actions were continuously implemented to assure ongoing compliance with government requirements
- Practiced the absolute strictest confidentiality, adhering to all HIPAA guidelines/regulations.
Medical Records Review Verification Specialist
Advantmed
12.2014 - 05.2017
- Reviewed all documentation performed by 2 nursing staff members for medical record abstraction according to the Healthcare Effectiveness Data and Information Set (HEDIS)
- Promptly developed recommendations for further corrective action based on medical review findings
- Collaborated with 2-4 multidisciplinary teams to promote corporate standards
- Interpreted and applied broad guidelines to specific and highly variable situations for over 50 patient medical records daily
- Utilized detail-oriented organization and critical thinking skills to administer patient advocacy on 1000’s of medical records claims data and thoroughly review and resolve errors as needed.
RN Business Owner
LJ & Donn
06.2010 - 09.2020
- Effectively managed and prioritized multiple diverse medical cases while working with minimal supervision to care for 1-3 patients monthly on a long-term basis to decrease hospitalization and optimize clients optimal level of health
- Established and maintained professional relationships with associates, patients, and families
- Proactively solved issues using in house resources, prioritizing importance, and reporting issues to physicians when needed to ensure safe and appropriate patient care.
Education
Bachelor Degree of Science in Nursing -
Chamberlain University- College of Nursing
01.2017
Associate Degree of Science in Nursing -
Excelsior College of Nursing Albany
01.2012
Practical Nursing Diploma -
State of Connecticut LPN Program
01.2010
Skills
- Registered Nursing
- Remote Nurse
- Managed Care
- Medical Records
- Clinical Quality Audits
- NCQA
- Patient Advocacy
- Documentation
- Medical Terminology
- Charting
- Microsoft Office
- Budget Oversight
- Time Management
- Organization
- Clinical judgment
- Compassion and Empathy
- Geriatric Care
- Health Promotion
- Direct Patient Care
- Patient Assessment
- Patient education and counseling
- Medication Administration
- Strong Clinical Judgment
- Patient Monitoring
- Physical assessments
- Licensed RN
- Care Plan Development
- Care Planning
- High level of autonomy
- HIPAA Education
- EMR / EHR
- Long-Term Care
- Acute care expertise
- Managing deadlines
- Medical evaluation
- Home care
- Data Collection
- Medical Records Management
- Medical Recordkeeping
Certification
- Licensed Practical Nurse, Connecticut Board of Nursing
- Licensed Registered Nurse, Connecticut Board of Nursing, 07/31/22, Yearly
- Licensed Registered Nurse, New York Board of Nurses, Biannually
Personal Information
Title: BSN, RN
Timeline
Clinical Quality RN-National Audit Team
United Health Group
01.2022 - Current
RN Clinical Quality Assurance Oversight HEDIS Specialist (CQO)
United Health Group
12.2017 - 12.2021
Medical Records Review Verification Specialist
Advantmed
12.2014 - 05.2017
Registered Nurse
Yale New Haven Hospital
06.2013 - 06.2015
RN Business Owner
LJ & Donn
06.2010 - 09.2020
Bachelor Degree of Science in Nursing -
Chamberlain University- College of Nursing
Associate Degree of Science in Nursing -
Excelsior College of Nursing Albany
Practical Nursing Diploma -
State of Connecticut LPN Program