Michelle Rozier
Jacksonville,FL
Summary
Registered nurse with experience in case management and utilization management. Experience with case management in home health, hospice, and health plan settings. Enhanced skills in medical necessity reviews, care plan development, benefit education, collaboration with healthcare teams, and educating patients and members.
Overview
21
21
years of professional experience
1
1
Certification
Work History
Registered Nurse- Utilization Management
Blue Cross Blue Shield/Florida Blue
03.2023 - Current
- Utilization Management – Conducted preservice reviews and concurrent reviews for medical necessity for prior authorization and inpatient reviews.
- Performed clinical review of procedures prior to care or treatment being rendered
- Conducted review for benefit coverage and medical necessity prior to rendering decisions
- Applied evidence-based criteria to conduct medical necessity reviews for pre-service authorizations and concurrent reviews for inpatient level of care criteria
- Applied medical knowledge in reviewing pre-service requests
- Utilized various Florida Blue platforms to conduct reviews (JIVA, Diamond, Provider Connect, Care Connect, Customer Connect), documented findings, consulted with medical director, and collaborated with team members
- Utilized Florida Blue Medical Coverage Guidelines, InterQual, CMS Guidelines, and Prior Authorization Tool to assist with conducting medical and pharmacy reviews
- Experience with ICD-10, CPT-4, and HCPC codes
- Experience with MS Word, Outlook, Excel, and Powerpoint
- Collaborated with interdisciplinary teams to develop care plans.
Registered Nurse- Care Manager
Blue Cross Blue Shield /Florida Blue
07.2017 - 03.2023
- Assisted members with making effective health care choices for self-management of their acute and/or chronic conditions: Diabetes, Hypertension, Heart Failure, Atrial Fibrillation.
- Utilized a member-centric approach to assist members and their families with understanding and managing their disease process through reinforcement of physicians’ plan of treatment, promotion of healthy behaviors, and lifestyle changes
- Developed individual care plans in collaboration with the member, physician, families, and care team
- Facilitated access to care and resources to meet the member’s health care needs
Registered Nurse- Case Manager
Covenant Care Hospice
07.2015 - 07.2017
- Assisted patients and families with end-of-life care
- Taught patients and families about medications, wound care, skin care, pain management, and supportive care
- Collaborated with other health care providers and doctors for developing individualized care plans for patients
Registered Nurse
Bay Medical Center
01.2015 - 12.2015
- Patient assessment and medical interventions
- Monitoring health conditions and collaborated with physicians on changes in patient conditions
- Documentation in electronic medical record
Registered Nurse- Case Manager Clinical Supervisor
Kindred at Home
09.2012 - 07.2015
- Collaborated with doctors, patients, and other health care professionals to develop individualized care plans for patients
- Educated patients and caregivers on aftercare and ongoing care
- Managed patients’ care plans according to physicians’ orders
- Supervised licensed practical nurses and home health aides
- Collaborated and provided guidance to other team members to revise and update care plans as patients’ needs and conditions changed.
- Answered calls and assisted with customer service tasks as patients, doctors, and family members called into the office.
- Entered data into the computer from paperwork that was submitted by members of the health care team.
- Transferred data from forms into the computer to generate electronic medical records
Registered Nurse- Case Manager
Alliance Care
12.2006 - 09.2012
- Collaborated with doctors, patients, and other health care professionals to develop individualized care plans for patients
- Educated patients and caregivers on aftercare and ongoing care
- Managed patients’ care plans according to physicians’ orders
Registered Nurse
Gulf Coast Medical Center
06.2004 - 11.2006
- Patient assessment and medical interventions
- Monitored health conditions and collaborated with physicians on changes in patient conditions
- Triaged patients in emergency situations
Education
Master of Science - Nursing
University of Texas at Arlington
Arlington, TX01.2017
Bachelor of Science - Nursing
Ohio University
Athens, OH01.2015
Associate of Science - Nursing
Gulf Coast Community College
Panama City, FL01.2004
Skills
- Medical necessity review
- Clinical documentation
- Care plan development
- InterQual criteria application
- Patient education
- Medical coverage guidelines
- NCQA standards for utilization management
Certification
- Registered Nurse (RN), Florida, RN 9221076, Multi-State License
- Registered Nurse (RN), California, RN 95433486
Timeline
Registered Nurse- Utilization Management
Blue Cross Blue Shield/Florida Blue
03.2023 - Current
Registered Nurse- Care Manager
Blue Cross Blue Shield /Florida Blue
07.2017 - 03.2023
Registered Nurse- Case Manager
Covenant Care Hospice
07.2015 - 07.2017
Registered Nurse
Bay Medical Center
01.2015 - 12.2015
Registered Nurse- Case Manager Clinical Supervisor
Kindred at Home
09.2012 - 07.2015
Registered Nurse- Case Manager
Alliance Care
12.2006 - 09.2012
Registered Nurse
Gulf Coast Medical Center
06.2004 - 11.2006
Master of Science - Nursing
University of Texas at Arlington
Bachelor of Science - Nursing
Ohio University
Associate of Science - Nursing
Gulf Coast Community College