Marcella Janes RN MSN CCM
Morro Bay,CA
Summary
Proactive and goal-oriented registered nurse specializing in utilization review, including prior authorization, retrospective review, appeals, concurrent review, and compliance within healthcare delivery systems. Expertise in fostering clear communication and enhancing collaboration among interdisciplinary teams, leadership, providers, and medical directors to drive effective patient care. Extensive clinical experience in emergency, critical care, and neuro-trauma environments informs strategic decision-making within the utilization review process, resulting in significant cost savings through appropriate service utilization within plan networks. Committed to optimizing quality of care by aligning clinical review processes with corporate, state, and federal compliance standards while championing the integration of innovative technologies to transform healthcare practices.
Overview
29
29
years of professional experience
1
1
Certification
Work History
Senior Clinical Review RN/Clinical Audit Consultant
Healthnet/Centene
Woodland Hills, CA
07.2016 - Current
- Executed thorough clinical reviews and internal clinical audits of denials for Medi-Cal, Medicare, and commercial plans.
- Collaborated with interdisciplinary teams to develop comprehensive patient care strategies and discharge plans.
- Led quality improvement initiatives that optimized resource utilization and enhanced overall patient satisfaction scores.
- Performed comprehensive clinical evaluations in alignment with InterQual standards and established medical policies to ensure compliance across all departments.
- Achieved cost savings of approximately $500,000 by transitioning contracted services from out-of-network to in-network providers.
- Applied clinical policies and compliance standards to perform detailed audits, facilitating accurate reporting and regulatory adherence.
- Conducted detailed training meetings with medical directors, focusing on interdisciplinary strategies to meet compliance standards.
- Evaluated regulatory compliance audit outcomes and established targeted action plans to drive process improvements.
Per Diem Concurrent Review RN
Cedars Sinai Medical Center
Los Angeles-Marina Del Rey, CA
09.2019 - 10.2020
- Applied InterQual screening criteria to assess patient needs and support authorization requests for inpatient medical services in an acute care environment.
- Conducted 28-33 inpatient concurrent reviews per day
- Interpreted clinical information and applied established medical criteria to assess necessity of services and procedures.
- Performed systematic clinical reviews to evaluate patient conditions and medical needs, adhering to hospital policies and regulatory standards for medical necessity.
- Collaborated with interdisciplinary teams to enhance patient outcomes, discharge planning and streamline care processes.
- Conducted comprehensive nursing assessments to evaluate discharge needs and care gaps to be addressed by care coordination
- Participated in ongoing professional development opportunities to stay current on best practices in nursing care and emerging trends in healthcare delivery.
RN Case Manager II
Healthcare Partners Medical Group
Torrance, CA
07.2014 - 07.2016
- Successfully reduced the readmission rates for chronically ill patients from 13 to 11% by identifying post discharge care gaps, needs assessments, education for post discharge care and follow up, addressing discharge needs and ensuring member engagement with follow up care.
- Streamlined case management processes by integrating electronic health record systems for improved documentation efficiency.
- Coordinated patient care plans to optimize health outcomes and enhance continuity of care.
- Participated in interdisciplinary rounds to diagnose and deliver high-quality treatment to patients in a primary care setting while addressing quality improvement opportunities.
- Effectively managed patients with complex chronic conditions and coordinated post discharge care to prevent readmission and worsening of disease by performing post discharge calls to identify any care or knowledge gaps.
- Implemented motivational interviewing and complex care coordination skills to improve patient outcomes.
Travel ICU RN- contract
Procel Corporation
Hermosa Beach, CA
01.2012 - 07.2014
- Functioned in an expert clinical ICU nurse capacity and Subject Matter Expert under exemplary flexible working environments and three contract assignments.
- Functioned under Title 22 in CA patient care with 1:1 and 2:1 ratio of patients
- Administered medications and monitored patient responses to ensure optimal care outcomes.
- Demonstrated expert level knowledge base and nursing practice where skill, communication and experience were essential to provide positive patient outcomes in a dynamic critical care environment.
- Collaborated with interdisciplinary teams to develop and implement individualized patient care plans.
Clinical Nurse III (Staff RN III)
Ronald Reagan UCLA Medical Center
Los Angeles, CA
04.2005 - 12.2011
- Executed critical care assessments and evaluations for trauma, neuroscience, transplant, cardiothoracic, and medical/surgical ICU patients.
- Facilitated inter and intra-facility transport of critically ill patients to support timely medical interventions and continuity of care.
- Executed management of sophisticated monitoring systems and responded to life-threatening medical situations as part of rapid response and code blue team.
- Led intravenous placement team, showcasing advanced peripheral IV insertion techniques.
- Oversaw management of central lines, invasive airways, ventilators, and multiple vasoactive drips in fast-paced environments.
- Engaged with interdisciplinary teams to streamline communication processes, improving the quality of intensive care delivery.
- Led the Code Blue and Rapid Response Team activation to internal medical emergencies
ICU RN contract
American Traveler
Boca Raton, FL
04.2004 - 04.2005
- Management of critically ill patients on vasoactive drips, management of airways and stabilized critical patients before, during and after procedures/surgeries.
- Inter-facility critical care transport of patients to and from radiology, emergent procedures
- Educated family members and caregivers on patient care instructions.
- Collaborated with interdisciplinary teams to develop comprehensive care plans for complex cases.
- Functioned as IV insertion team member
- Functioned as Code Blue/Emergency/Rapid Response Team
- Administered and titrated ordered medications and treatments in accordance with established protocols and patient care plans.
- Collaborated with interdisciplinary teams to enhance patient outcomes and streamline care processes.
- Mentored junior nurses on best practices and clinical procedures to improve skill competency.
- Implemented quality improvement initiatives that enhanced patient safety and satisfaction scores.
ICU RN contract
Medical Express
Denver, CO
01.2004 - 04.2004
- Provided comprehensive care for critically ill trauma patients in cardiothoracic medical/surgical ICU to ensure optimal recovery.
- Utilized critical thinking skills to prioritize nursing interventions based on patients'' acuity levels and individual needs.
- Conducted detailed nursing assessments and formulated care plans to enhance patient care and evaluate treatment effectiveness.
- Administered vasoactive medications, including drips, to stabilize and monitor patient vital signs effectively.
- Navigated dynamic healthcare settings by effectively shifting to alternate departments in response to varying acuity and care needs.
ICU RN Per Diem
UC Davis Medical Center
Sacramento, CA
05.2003 - 01.2004
- Provided comprehensive bedside care to critically ill patients in surgical ICU to enhance recovery outcomes following head and neck procedures.
- Executed comprehensive patient assessments to promptly identify condition changes and ensure timely physician notification.
- Managed administration of vasoactive medications while closely monitoring patient vital signs to enhance emergency response effectiveness.
- Facilitated patient and family education on health management to enhance understanding and adherence to treatment plans.
- Championed patient advocacy during multidisciplinary meetings to enhance care coordination across services.
ICU RN Staff Full-Time
Barton Memorial Hospital
South Lake Tahoe, CA
07.1999 - 05.2003
- Delivered evidence based care to critically ill patients in a rural hospital setting.
- Skillfully managed challenging patient situations using de-escalation techniques, crisis intervention strategies, and therapeutic communication skills.
- Conducted thorough patient assessments to identify changes in condition, promptly notifying physicians and initiating appropriate interventions when necessary.
- Administered medications and treatments per established protocols, ensuring patient safety and compliance with regulations
- Collaborated with multidisciplinary teams to develop and implement individualized care plans for diverse patient populations.
- Monitored vital signs and assessed patient conditions, promptly reporting changes to physicians for timely intervention.
New Graduate Training Full Time Staff RN
Desert Regional Medical Center
Palm Springs, CA
02.1997 - 07.1999
- New graduate RN training program, preceptor led learning, applying nursing theory and principles into practice
- Assessed patient conditions, identifying critical changes and implementing timely interventions to address needs in medical/surgical and telemetry environment.
- Developed proficiency in intravenous and Foley catheter insertion to support clinical procedures.
- Administered medications and treatments per established protocols to ensure patient safety and compliance.
- Monitored and refined infection control practices to promote a safe healthcare environment and reduce transmission rates.
- Educated patients and families on health management, enhancing understanding of treatment options and recovery processes.
Education
Master of Science - Nursing
Walden University
Minneapolis, MN03-2014
Associate of Science - Nursing
College of The Desert
Palm Desert, CA12-1996
Skills
- Utilization Clinical Review
- Clinical Auditing
- Denials and Work processes
- Critical Thinking
- Problem Solving
- Project Management
- Interdisciplinary Collaboration
- Nursing Assessment
- Discharge Planning
- Care Planning
- AI and Copilot experience
Certification
- Registered Nurse (RN), CA, #529801, expires 05/28
- Certified RN Case Manager (CCM), #4219663, expires 05/31
- ACLS, Recert in process
- BLS, Recert in process
- PALS, Recert in process
Personal Information
Title: RN MSN CCM
Timeline
Per Diem Concurrent Review RN
Cedars Sinai Medical Center
09.2019 - 10.2020
Senior Clinical Review RN/Clinical Audit Consultant
Healthnet/Centene
07.2016 - Current
RN Case Manager II
Healthcare Partners Medical Group
07.2014 - 07.2016
Travel ICU RN- contract
Procel Corporation
01.2012 - 07.2014
Clinical Nurse III (Staff RN III)
Ronald Reagan UCLA Medical Center
04.2005 - 12.2011
ICU RN contract
American Traveler
04.2004 - 04.2005
ICU RN contract
Medical Express
01.2004 - 04.2004
ICU RN Per Diem
UC Davis Medical Center
05.2003 - 01.2004
ICU RN Staff Full-Time
Barton Memorial Hospital
07.1999 - 05.2003
New Graduate Training Full Time Staff RN
Desert Regional Medical Center
02.1997 - 07.1999
Associate of Science - Nursing
College of The Desert
Master of Science - Nursing
Walden University