Monique Broxton
Belleville,US
Summary
Self-motivated licensed practical nurse with 9.5 years of managed care experience. Enthusiastic and eager to contribute to team success through hard-work, attention to detail and excellent organizational skills. Clear understanding of Utilization Management, CMS Guidelines and InterQual criteria.
Overview
10
10
years of professional experience
Work History
Prior Authorization Nurse
Centene Corporation
Detroit, Michigan
01.2020 - Current
- Review prior authorizations according to policy
- Identify appropriate benefits, eligibility, and expected length of stay for members requesting new treatments and/or procedures
- Participate in interdepartmental integration and collaboration to enhance the continuity of care for members
- Maintain department productivity and quality measures
- Conduct team audits
- Precepting new hires on prior authorization processes for all service types
- Attend regular staff meetings
- Complete assigned work plan objectives and projects on a timely basis
- Maintain professional relationships with provider community and internal and external customers
- Maintain cooperative and effective workplace relationships and adheres to company Code of Conduct
- Consult with and refer cases to medical directors as necessary
- Comply with required workplace safety standards
Clinical Care Supervisor
Meridian Health Plan
Detroit, Michigan
08.2017 - 12.2019
- Oversee changes to medical service functions and performance in relation to company mission, philosophy objectives and policies, as directed
- Assist senior management with budgets and forecast for strategic planning and key initiatives
- Balance current future needs effectively
- Ensure compliance with established onsite and concurrent review, case management, referral, preauthorization policies, procedures, and processes
- Assure that Medical Services functions and responsibilities are coordinated with other operating departments of the Plan and Corporate
- Assist senior management with statistical analysis of utilization data
- Participate in NCQA accreditation of the Plan
- Participate in case review with Medical Directors and act as resource for appeals function
Health Manager
Molina Healthcare
Troy, MI
05.2016 - 07.2017
- Accept and review clinical referrals from multiple sources daily
- Assign referrals via internal system to Case Managers on daily basis
- Utilize a collaborative process for assessments, planning, implementation and evaluation, to engage, educate, and promote members decisions related to achieving and maintaining optimal health status
- Conduct standardized Health Risk Appraisals (HRA) and condition specific assessments, including the verification of medical history and current health and wellness needs
- Conduct telephonic education to promote self-management strategies for specific chronic conditions
- Utilize evidence based standardized protocols for self-management of specific chronic conditions or other health conditions
- Participate in team case conferences to ensure collaboration to optimize interventions for high-risk members
- Coordinate health management activities with state-based health plan teams
- Access and Monitoring, Case Management, Behavioral Health, Member Services and work with the participants' Primary Care Provider as necessary to support the member in the Health Management Program
- State plan / department specific duties and responsibilities
Care Review Clinician
Molina Healthcare
Troy, MI
08.2015 - 04.2016
- Provide prior authorizations according to policy
- Identify appropriate benefits, eligibility, and expected length of stay for members requesting new treatments and/or procedures
- Participate in interdepartmental integration and collaboration to enhance the continuity of care for members including Behavioral Health and LongTerm Care
- Maintain department productivity and quality measures
- Attend regular staff meetings
- Complete assigned work plan objectives and projects on a timely basis
- Maintain professional relationships with provider community and internal and external customers
- Maintain cooperative and effective workplace relationships and adheres to company Code of Conduct
- Consult with and refers cases to medical directors regularly, as necessary
- Comply with required workplace safety standards
Education
Practical Nursing Certificate -
Oakland University
Rochester, MI01.2011
Skills
- Proficient in Microsoft Word, Excel, PowerPoint
- Experienced in InterQual Criteria
- Excellent Decision-Making Skills
- Strong communicator
Timeline
Prior Authorization Nurse
Centene Corporation
01.2020 - Current
Clinical Care Supervisor
Meridian Health Plan
08.2017 - 12.2019
Health Manager
Molina Healthcare
05.2016 - 07.2017
Care Review Clinician
Molina Healthcare
08.2015 - 04.2016
Practical Nursing Certificate -
Oakland University