Nicole Barnes
Plano,Tx
Summary
Dedicated nursing professional with extensive experience in case management, skilled in conducting thorough patient assessments and coordinating comprehensive care plans. Committed to fostering collaborative team dynamics and adapting to evolving healthcare needs to ensure optimal patient outcomes. Recognized for exceptional communication skills and a proactive problem-solving approach, consistently achieving results in fast-paced environments. Passionate about enhancing patient experiences through strategic planning and compassionate care.
Overview
8
8
years of professional experience
1
1
Certification
Work History
Telephonic Nurse Case Manager
Wellmed Medical Management
04.2024 - 01.2025
- Developed expertise in assessing patient needs and providing appropriate interventions to improve health outcomes.
- Demonstrated ability to effectively communicate with patients, families, physicians and other healthcare providers.
- Applied sound judgment when making decisions related to patients' eligibility criteria for programs or services offered by the organization.
- Identified areas of improvement within existing processes and procedures and recommended solutions accordingly.
- Utilized strong problem-solving skills to efficiently manage multiple cases simultaneously while ensuring quality care.
- Proficiently navigated various electronic systems including EMRs and data analytics tools to review patient information, track outcomes, and document notes.
- Performed detailed assessments of patient's physical and mental health status through telephonic interviews.
- Fostered relationships with external organizations such as home health agencies or community resources for additional support services when needed.
- Gathered pertinent information from family members or caregivers during phone conversations in order to develop comprehensive understanding of patient's condition.
- Provided feedback on denials and approvals to provider staff on a regular basis through verbal or written communication methods.
- Conducted concurrent reviews for inpatients using InterQual criteria, managed care policies and other resources such as Milliman Care Guidelines.
- Performed utilization reviews for inpatient and outpatient services to ensure medical necessity, appropriateness of care and level of service according to state and federal regulations.
- Applied review criteria to compile accurate accounts of patients' clinical circumstances.
- Monitored trends in utilization patterns within assigned caseloads to ensure compliance with plan requirements.
- Researched complex cases involving multiple diagnoses or treatments requiring additional analysis beyond standard criteria.
- Committed to delivering excellent customer service while working in a fast-paced environment.
- Focused on learning new skills and staying updated with industry changes.
- Participated in ongoing training to enhance own job skills and knowledge.
- Provided efficient and courteous service to customers at all times.
- Met deadlines while maintaining high-quality deliverables.
- Managed up to 10 facilities (with up to 5 level I hospitals) and coordinated multiple projects while ensuring timely completion.
- Collaborated with departmental leaders to establish organizational goals, strategic plans and objectives.
- Proactively identified opportunities for improving processes related to prior authorization requests.
- Demonstrated exceptional attention to detail when reviewing prior authorization forms for accuracy and completeness.
- Ensured that all required documentation is maintained in accordance with company policy.
- Kept informed regarding pending industry changes, trends, and best practices.
Registered Nurse Case Manager, Hospice
Accord Hospice
09.2023 - 04.2024
- Collaborated with interdisciplinary team members to ensure the highest quality of care was provided to all patients.
- Educated staff on current trends in hospice care related to symptom management, end-of-life issues, bereavement support and advance directives.
- Identified potential problems or areas requiring further intervention through ongoing assessments throughout the course of care.
- Assisted in coordinating services between multiple agencies including medical providers, DME companies, Hospice Aides and Volunteers.
- Facilitated regular meetings with family members, caregivers discussing updates on patient status, treatment plans, goals and available resources within the community.
- Managed complex up to 25 medical cases by providing guidance on medications and treatments necessary for symptom control or palliation.
- Demonstrated strong leadership skills while managing a large caseload of diverse patient cases.
- Maintained accurate documentation according to agency standards, ensuring compliance with state regulations.
- Ensured compliance with established quality control guidelines.
(Contract) Registered Nurse
Shiftkey
11.2022 - 01.2024
- Transferred clients to alternative providers according to their progress.
- Worked with teams to ensure care plans fit patient requirements and coverage.
- Coordinated client access to social services, health care providers and governmental agencies.
- Facilitated discharge planning by coordinating referrals to post-acute care services as needed.
- Reviewed utilization review criteria to align with current standards.
- Stayed informed about diverse benefit plans.
- Evaluated suitability of medical services using clinical documentation.
- Performed thorough evaluations of patient files to confirm medical necessity.
- Escalated cases for secondary review when criteria were not met.
- Streamlined discharge procedures to support ongoing patient management following hospitalization.
- Connected family with suitable community resources.
- Enhanced communication among medical teams, families, and support entities.
- Instructed up to 30 patients about different disease processes, treatments, medications, and lifestyle changes.
- Performed detailed analyses of patient's medical records and necessities.
- Analyzed laboratory findings and imaging results for designated patients.
- Updated care plans in response to clients' progress.
- Handled customer inquiries to deliver dependable service and meet operational benchmarks.
- Maintained detailed documentation related to all reviews including notes from conversations with providers and members.
- Documented correct records of clinical treatment to minimize coding errors and denied claims.
- Maintained comprehensive awareness of insured treatment options by examining specific policy conditions.
- Assisted with development of new protocols related to utilization review procedures.
- Mediated communication between care providers and patients for clarifying treatment options.
- Developed strong relationships with patients through compassionate communication techniques.
- Educated individuals and families on health education and disease prevention.
- Ensured compliance with all safety standards and regulations.
- Ensured compliance with applicable regulations regarding information security.
Registered Nurse
Haven Behavioral Hospital
01.2021 - 11.2022
- Provided comprehensive case management services to a diverse patient population, including assessment of patients' needs and development of individualized care plans.
- Established strong working relationships with other departments within the organization to ensure seamless coordination of care.
- Demonstrated excellent communication skills in interacting with patients, families and other healthcare providers.
- Liaised with multidisciplinary teams to organize and coordinate health and care services to meet patients' complex care needs.
- Utilized critical thinking skills when making decisions about patient's care plans or referral sources.
- Monitored changes in condition ( or treatment plan compliance through regular follow-up calls and visits of 20-30 adolescents.
- Taught patients and significant others to manage illness or injury by explaining post-treatment home care needs.
- Provided crisis intervention services when needed during acute episodes.
- Facilitated transitions between levels of care using evidence based practice guidelines.
- Utilized research-based best practices to ensure quality outcomes and reduce costs associated with hospitalizations.
RN Case Manager
Medical City of Plano
07.2021 - 12.2021
- Referred patients to specialized health resources and community agencies for further assistance.
- Consulted and coordinated with healthcare team members to plan, implement, or evaluate patient care plans.
- Used computers to complete necessary patient charts and documentation on patients' progress.
- Created effective relationships with outside organizations, including hospitals, rehabilitation centers, and skilled nursing facilities, in order to ensure a smooth transition of care for discharged patients.
- Collaborated with physicians, nurses, and other healthcare professionals to ensure the best outcomes for patients.
- Conducted comprehensive assessments of patient's current health status to determine eligibility for case management services.
- Assessed patients' physical, psychological, and social conditions to identify appropriate interventions of multiple hospital floors (up to 5 floors; ER, CC, Ortho, Delirium, Cardiac).
- Developed and implemented utilization management policies and procedures to ensure compliance with regulatory guidelines.
- Participated in interdisciplinary meetings with members of the healthcare team and insurance companies in order to discuss patient care issues and coordinate appropriate services and resources required by the patient's plan of care.
- Identified areas for improvement within the organization's utilization management program.
- Conducted reviews of patient records to identify potential opportunities for quality improvement initiatives.
- Collaborated with case managers in developing individualized discharge plans for complex cases.
- Performed concurrent reviews by analyzing medical records in order to determine if services are medically necessary according to established criteria.
- Utilized a variety of software applications such as MS Office Suite, spreadsheet programs.
Registered Nurse Case Manager
Ultimate Home Health & Hospice
01.2021 - 07.2021
- Attended interdisciplinary meetings to discuss complex cases and provide input regarding appropriate course of action.
- Provided comprehensive case management services to a diverse patient population, including assessment of patients' needs and development of individualized care plans.
- Established strong working relationships with other departments within the organization to ensure seamless coordination of care.
- Liaised with multidisciplinary teams to organize and coordinate health and care services to meet patients' complex care needs.
- Assisted in developing policies and procedures related to case management functions.
- Evaluated effectiveness of (up to 25) treatment plans daily & regularly utilizing data collection tools such as surveys or questionnaires.
- Utilized advanced conflict resolution skills as necessary to ensure timely resolution of issues.
Registered Nurse, Medical-Surgical Unit
Texoma Medical Center
02.2018 - 01.2020
- Efficiently accomplished service goals through task prioritization and organization.
- Attended team meetings for interdisciplinary discussions on complex cases.
- Provided clients with knowledge about their health issues and strategies for management via lifestyle adjustments and medication.
- Designed patient treatment plans, optimizing use of resources.
- Assessed patient and family dynamics to identify psychosocial support needs.
- Conducted reviews to assess suitability of medical care.
- Engaged in cross-disciplinary team discussions on challenging cases necessitating approval for specialized services.
- Leveraged multiple software applications to enhance operational workflows.
- Demonstrated effective teamwork to boost workplace productivity.
- Collaborated with various departments to reach objectives.
- Ensured up-to-date data on charts for stringent documentation standards.
- Observed surgical patients, addressed queries, delivered post-surgery care recommendations.
- Coordinated with medical professionals to reduce risks of return hospitalization.
- Utilized advanced expertise to implement effective solutions for complex issues.
- Delivered outstanding customer service in-person and via phone.
- Reduced compliance issues through supportive interaction in challenging situations.
- Implemented tailored nursing care strategies based on patient evaluations.
- Produced instructional resources for patient and family learning.
- Counseled patients on medication side effects to enhance understanding.
- Participated in efforts to improve quality metrics.
- Delivered education tailored to chronic illness patients.
- Supervised post-surgical patients to ensure recovery.
- Communicated critical observations to physicians to support informed decision-making.
- Executed rapid and accurate assessments of clinical situations through critical analysis.
- Ensured compliance with relevant regulations at all times.
- Ensured compliance with established quality control guidelines.
- Monitored regulatory changes impacting the organization's compliance standards.
- Monitored compliance with relevant legislation, regulations and policies.
- Managed caseload of 5 patients simultaneously by providing bedside care, treatments, IV therapy, and wound care.
Registered Nurse
Carrollton Springs Hospital
06.2017 - 07.2018
- Contributed to collaborative meetings aimed at optimizing care plans.
- Orchestrated discharge plans for patients moving from care facility to home.
- Delivered case management services through intake, assessment, crisis intervention and referral processes.
- Coordinated engagement with social services and health providers to enhance clients' individual independence (up to 25 patients).
- Adjusted treatment plans to reflect shifts in clients' health and progress.
- Evaluated treatment plans for consistency with individual goals.
- Teamed with physicians to ensure treatments aligned with clients' medical needs.
- Managed support services and enhanced communication between healthcare staff and patients.
- Managed multiple tasks while providing timely, high quality patient care.
- Prioritized workloads based on changing clinical situations.
- Maintained confidentiality in patient matters to comply with HIPAA guidelines and measures.
- Collected relevant diagnoses and plans of care by querying clinical staff attending to patients.
- Researched relevant legislation, regulations, guidelines, and standards impacting the organization's operations.
- Participated in cross-functional teams responsible for developing innovative solutions that meet all applicable legal requirements.
- Assessed current systems against established requirements to ensure adequate controls were in place.
- Maintained detailed records of all compliance activities performed by the organization.
- Ensured that all employees were aware of their responsibilities regarding corporate compliance matters.
- Identified compliance issues that required follow-up and investigation.
Education
Doctorate -
Liberty University
Lynchburg, VA08.2028
Bachelor of Science - Social Work & Nursing
Midwestern State University
Wichita Falls, TX05.2017
Skills
- Utilization review
- Benefit plan knowledge
- Effective communication
- Quality improvement
- Teamwork and collaboration
- Work Planning and Prioritization
- Clinical judgment
- Healthcare systems navigation
- Clinical assessment
- Data entry
- Case management
Accomplishments
- Achieved above excellence in leadership recognition by completing Liberty University (2-month) Coursework with accuracy and efficiency (May 2025).
Certification
- (Compact) RN license
- AHA BLS (2027)
Timeline
Telephonic Nurse Case Manager
Wellmed Medical Management
04.2024 - 01.2025
Registered Nurse Case Manager, Hospice
Accord Hospice
09.2023 - 04.2024
(Contract) Registered Nurse
Shiftkey
11.2022 - 01.2024
RN Case Manager
Medical City of Plano
07.2021 - 12.2021
Registered Nurse
Haven Behavioral Hospital
01.2021 - 11.2022
Registered Nurse Case Manager
Ultimate Home Health & Hospice
01.2021 - 07.2021
Registered Nurse, Medical-Surgical Unit
Texoma Medical Center
02.2018 - 01.2020
Registered Nurse
Carrollton Springs Hospital
06.2017 - 07.2018
Doctorate -
Liberty University
Bachelor of Science - Social Work & Nursing
Midwestern State University
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