Michelle Tallmadge
Gladewater,TX
Summary
Certified Telephonic Case Manager/Utilization Review Nurse with over 15 years of experience with demonstrated accomplishments in the evaluation of treatment plans for medical necessity, appropriateness of treatment, and cost-effective compassionate care for patients in a Workers Compensation environment.
Overview
19
19
years of professional experience
1
1
Certification
Work History
TELEPHONIC NURSE CASE MANAGER/UTILIZATION REVIEW/MEDICAL AFFAIRS REVIEW NURSE
AIG DALLAS/HEALTH DIRECT INC.
04.2008
- Facilitating quality case management services in an appropriate, cost-effective manner to employees who are receiving benefits under Workers' Compensation
- Reviewing case records and reports, collecting and analyzing data, evaluating client's medical and vocational status and defining needs and problems in order to provide proactive case management services
- Rendering opinions regarding case costs, treatment plan, outcome and problem areas, and making recommendations to facilitate rehabilitation goals and return to work
- Facilitating timely return to work date by establishing a professional working relationship with the client, physician, and employer
- Coordinating return to work with patient, employer and physicians
- Maintaining contact and communicating with insurance adjusters to apprise them of case activity, case direction or receive authorization for services
- Maintaining contact with all parties involved on case, necessary for case management for the client
- Meeting monthly production requirements and quality assessment (QA) requirements to ensure a quality product
- Performing initial, concurrent, retrospective and expedited reviews for Workers Compensation patients utilizing evidence-based medical guidelines to determine the medical appropriateness of inpatient and outpatient services
- Using knowledge of the nursing process and pathophysiology to interpret the needs or requirements of patients and escalate complex cases for Peer Review Physician as required
- Reviewing medical records to verify that the content supports an appropriate treatment being requested
- Reviewing medical records for treatment appropriateness, causality, medication management per adjustor directive and coordinating continuum of care with peer review.
UTILIZATION REVIEW NURSE
NEXUS
11.2022 - Current
- Analyzing medical records and providing clinical documentation for review in multiple states including: Arkansas, California, Colorado, Florida, Illinois, Louisiana, Massachusetts, Michigan, New York, North/South Carolina and Texas
- Gathering demographics, clinical information on prospective, concurrent, retrospective, inpatient/outpatient treatments, appeals and determining medical necessity for treatments
- Creating professional executive reports to include summary, appropriate criteria/guidelines and rationale using evidence based guidelines
- Utilizing pre-approved criteria and guidelines to validate medical necessity/appropriate treatment such as ODG, CAMTUS, ACOEM, New York, CO, MA, and Louisiana Medical Treatment Guidelines
- Utilizing dragon dictation software to create reports
- Responsible for amending reports when necessary when additional clinical information is provided
- Participating in an interdisciplinary health care team to achieve positive outcomes.
CHARGE NURSE / PRECEPTOR
MEDICAL CENTER OF PLANO
08.2005 - 04.2008
- Performing Charge Nurse duties
- Providing care and associated therapies to Med/Surg, Neuro medical and neurosurgical patients
- Performing telemetry monitoring and care for pre-op, post-op surgical patients
- Conducting admission histories, assessment and discharge planning.
Education
Bachelor Of Science - Nursing
College of Mount Saint Vincent
The Bronx, NY05.1998
Skills
- Team Leader
- Proficient Utilization Review
- Cross-functional Collaboration
- Learning Agility
- Great Communicator (Verbal/Written)
- Exceptional Case Management
- Superb Trainer/Preceptor
- Time Management
- Strategic Thinker
- Team Development
- Crisis Management
- Delegation
- Microsoft Office Applications (Word, Excel, PowerPoint, Outlook) and Content Management System (CMS) Workers Compensation software
Affiliations
Case Management Society of America (CMSA)
Educationandcredentials
Bachelor of Science in Nursing, College of Mount St Vincent, New York, NY, 05/1998, Registered Nurse, Texas, 2003, Present, Registered Nurse, New York, 1999, 2007, BLS Certification, CCM through Commission for Case Manager Certification (CCMC), 12/2010, Present, Geriatric Care, Infection Control, Preceptorship
Selectedhighlights
- Skilled in performing Case Management Services for injured workers in multiple states: California, Arkansas, and New York.
- Proficient in performing Utilization reviews using medical treatment guidelines such as New York Medical Treatment Guidelines, Official Disability Guidelines by MCG, and California MTUS/ACOEM.
- Strong interpersonal and organizational skills; effective communicator with patients, families, physicians, Attorneys, Employers, and other healthcare professionals.
- Recognized as an excellent trainer/preceptor with the ability to lead and motivate others to higher levels of performance.
- Dedicated, patient-focused with a strong commitment to ensuring cost-effective care while optimizing quality.
Certification
Certification in case management
Certification in legal nurse consultation
Timeline
UTILIZATION REVIEW NURSE
NEXUS
11.2022 - Current
TELEPHONIC NURSE CASE MANAGER/UTILIZATION REVIEW/MEDICAL AFFAIRS REVIEW NURSE
AIG DALLAS/HEALTH DIRECT INC.
04.2008
CHARGE NURSE / PRECEPTOR
MEDICAL CENTER OF PLANO
08.2005 - 04.2008
Bachelor Of Science - Nursing
College of Mount Saint Vincent
Certification in case management
Certification in legal nurse consultation
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