Overview
30
30
years of professional experience
Work History
Utilization Management (UM) Review Nurse
SureCo (UHSM)
07.2021 - Current
- Responsible for prior authorization reviews for outpatient, inpatient and discharge management of UHSM members
- Review medical records and align treatment with evidence-based guidelines
- Analyze patient conditions to determine medical necessity for hospitalizations and total length of stay (TLOS)
- Manage caseload of prior authorizations based on medical necessity guidelines and plan benefits
- Review Prior Authorizations and provide appropriate diagnosis codes based on International Classification of Diseases (ICD) and Current Procedural Terminology (CPT) guidelines
- Train and mentor nurses in role of UM Nurse; provide oversight for additional training with reviews when needed
- Provide cost savings by utilizing preferred network and benefit plan policies
- Manage all appeals within 14-day turnaround time
- Collaborate with allied health personnel to ensure the best patient outcomes.
Special Account Quality Care/Auditor (weekdays)
Sedgwick (Formally York Risk Services Group)/CareWorks
09.2018 - 09.2020
- Provided telephonic, task assignments, and field case management services for insurance carriers, employers, and Third-Party Administrators
- Provided in-hospital case management assessments for discharge planning for injured patients
- Collaborated with providers of skilled nursing facilities (SNF) and In-Patient Rehab facilities for in-patient transfers and discharges
- Arranged and facilitated homecare, durable medical equipment (DME), and diagnostic services for injured patients
- Responsible for direct and indirect cost savings on case files through utilization review and negotiations
- Completed case management reports as required by Utilization Review Accreditation Commission (URAC) and claims account instructions for all case referrals: including initial, progress, summary, return to work (RTW), cost savings, pharmacy oversight reviews, and closure reports
- Facilitated injured employees successful RTW process with job analyses and reviews of full duty/modified duty job descriptions
- Established and maintained working relationships with employers, adjusters, and providers, in collaboration with the medical management of claims files
- Assigned to Quality Care Team to provide reviews and peer audits and recommendations for case management processes and perform edits to reports which meet the special accounts handling procedures
- Responsible for case manager training for special accounts handling procedures, reporting processes, and evaluations of work product
- Developed Special Accounts Workflow for national case management team and care management (CM) contractors.
RN Medical Case Manager
ExamWorks Clinical Solutions
08.2016 - 09.2018
- Provided telephonic and field case management services for insurance carriers, employers, and Third-Party Administrators
- Provided in-hospital case management assessments for discharge planning for injured patients
- Arranged and facilitated homecare, DME, and diagnostic services for injured patients
- Responsible for direct and indirect cost savings on case files through utilization review and negotiations
- Collaborated with adjusters and providers regarding medical management of claims files.
RN Medical Case Manager
Corvel
01.2016 - 08.2016
- Managed workers' compensation telephonic and field cases for insurance carriers, employers, and Third Party Administrators
- Completed Nurse File Reviews and Reports for liability and workers' compensation claims
- Responsible for direct and indirect cost savings on case files through utilization review and negotiations
- Facilitated injured employees RTW process with job analyses and review of modified duty job descriptions
- Established and maintained working relationships with employers, adjusters, and providers, in collaboration with the medical management of claims files
- Completed in-person beneficiary needs assessments and reports for insurance carriers
- Completed case management reports as required by URAC and claims account instructions for all case referrals: including initial, progress, summary, RTW, cost savings, and closure reports.
RN Field Care Coordinator
APS Healthcare (as subsidiary of Universal American, Inc)
06.2013 - 10.2015
- Provided case management and care coordination for Medicare Accountable Care Organization (ACO) beneficiaries
- Responsible for reducing hospitalizations within the ACO Georgia (GA) population by 50%
- Provided educational training sessions for Primary Care Providers regarding Medicare quality measures, tracking databases, care coordination and ACO processes
- Responsible for reviewing medical records for needs of care coordination and special beneficiary needs that are available through the ACO
- Scheduled Annual Wellness Exams and promotes Medicare Quality Measures Guideline Tools with providers as set forth by Medicare Guidelines
- Organized and participated in onsite 'Health Aging Expos and Wellness Health Fairs' at participating ACO provider offices.
Regional Sales Executive
Wright Rehabilitation Services, Inc
06.2006 - 01.2012
- Responsible for launching sales growth and development of case management vendor/nurse network throughout Georgia and Alabama
- Developed and maintained client relationships with employers, third party administrators, and insurance carriers
- Closed large national client private label contract which generated greater than 50% total revenue for southeast
- Responsible for sales in products and services of field and telephonic case management, vocational rehabilitation, Medicare set-asides, medical cost projections, life care plans, and litigation services.
Regional Sales Director
Southeast One Call Medical Inc.
11.2005 - 04.2006
- Managed One Call Medical (OCM) field sales team for Southeast-OCM purchased Occupational Solutions
- Responsible for hiring and management of southeast sales team throughout Georgia, Alabama, North Carolina, South Carolina, and Tennessee
- Trained and mentored sales executive representatives for sales results improvement and career development
- Prepared and created unique continuing education courses for clients and presented to both prospective and current clients
- Facilitated with the credentialing and participation of additional magnetic resonance imaging (MRI) facilities and electromyography (EMG) providers to become part OCM network providers
- Responsible for driving sales to produce greater than 35% of company total referral revenue.
Account Executive
One Call Medical/Occupational Solutions/Medquest Associates, Inc.
02.2003 - 11.2005
- Responsible for growth of Georgia territory sales to workers' compensation and insurance clients
- Maintained and developed relationships with large third party administrators such as Gallagher Bassett, AIG, ACE/ESIS, and Travelers on a national level
- Developed and led the national sales force in forming multi-sponsored events for large employer clients such as Coca-Cola and Delta Airlines
- Developed programs and presentations for radiologists and submitted these programs for continuing education units (CEUs) provider status
- Presented and coordinated over 35 CEU training courses for workers' compensation clients including the State of Georgia, Summit, WAUSAU, Ryder Shared Services, CNA, Builders Insurance, Crawford and Company, Gallagher Bassett, and Underwriters Safety Claims, etc
- Developed co-marketing initiatives with other workers' compensation service providers creating networking pathways
- Developed request for proposals (RFPs) and closed service and referral agreements for large employers and national insurance carriers
- Established territory growth of 200% in 1½ years
- Consistent Top Leader of Sales in nation for Occupational Solutions.
Center Administrator
MedQuest Associates, Inc.
05.2001 - 02.2003
- Responsible for management of all operations, revenue, and marketing for radiology imaging center
- Developed employee incentive programs for customer service programs and staff performance
- Hired and trained individuals to Medquest's employee standards
- Developed coaching plans and cross-training programs for all employees
- Enforced policies and procedures with exemplary leadership
- Strategically planned and consulted with other Center Administrators in a team effort to develop relationships and contracts throughout inter-territories
- Developed and marketed workers' compensation account in support with Occupational Solutions (Medquest's Workers' Comp Referral Company)
- Presented contracts, services, costs savings reports, and developmental needs for w/c accounts
- Conducted formal presentations to physicians, medical assistants, and office personnel on the topics of insurance/payers, services available, contracting, and image quality/technical capabilities
- Implemented insurance contracts for ancillary services.
Medical Management Specialist
Royal & SunAlliance Insurance
10.1999 - 05.2001
- Specialized in field case management for workers' compensation insured clients
- Collaborated with physicians, hospital personnel, employers, and accounts to perform essential field case management activities
- Arranged medical treatment for injured workers by referrals, independent medical exam appointments and second opinion appointments
- Facilitated in-person assessments with injured workers and meetings with employers to help develop return to work plans and modalities
- Performed job analyses onsite with employers and employees
- Coordinated services with accounts and medical providers for partnerships in workers' compensation industry
- Arranged and negotiated rates with vendors to achieve field case management cost effectiveness goals
- Negotiated special contracted rates for panel physicians, home care, durable medical equipment, and inpatient and out-patient hospital services.
Workers Compensation Case Manger
RTW, Inc
05.1997 - 05.1999
- Performed function of case manager for telephonic and field specialty
- Reviewed medical documentation to help claims professionals determine compensability decisions
- Maintained and serviced accounts currently insured, conducted employer orientations and sales meetings with accounts and employers to set expectations of RTW and safe working environments
- Arranged and facilitated meetings with claims professionals and prospective corporate clients to present 'RTW Advantage' marketing presentation
- Developed drug/alcohol policies, safety programs, employer guidelines, and pricing structures for services provided (Preferred Provider Organization [PPO] networks)
- Retained client accounts by monitoring and conducting quarterly meetings with insured for claims review, overall satisfaction of services, and work safety environment.
Registered Nurse
StarMed Health Personnel
05.1997 - 10.1999
- Performed functions of a registered nurse in various clinical hospital settings throughout St
- Louis, MO
- Worked in clinical areas of Intensive Care, Critical Care, Cardiovascular Intensive Care, and Telemetry on per diem monthly basis.
Registered Nurse
Lutheran Hospital
12.1996 - 03.1997
- Contract Travel Assignments (Telemetry and ICU).
Registered Nurse
Cibola General Hospital
08.1996 - 11.1996
- Contract/Travel Assignment (EM & ICU).
Registered Nurse
Dale County Department of Home Health State of Alabama
12.1995 - 08.1996
- Performed functions of home health nurse
- Managed case load of 40-55 patients requiring all aspects of home care
- Arranged patients' medical treatment/referrals and purchased medical supplies and durable medical equipment under guidelines of Medicare, Medicaid and other insurance plans
- Performed quality assurance checks and monitoring with patients and patients' families regarding services and medical equipment
- Managed team of 10 home health aides and performed evaluation assessment care checks monthly to monitor home health aides.
Registered Nurse
Dale Medical Center Hospital
03.1994 - 12.1995
- RN duties in ICU.
Certification
- Certified Case Manager
Summary
Analytical and strategic registered nurse with excellent problem-solving and time management skills. Organized, efficient, and always willing to go extra mile to meet expectations.
Skills
- Clinical Documentation
- Patient and Family Education
- Diabetes Management
- Nursing Plan Development
- Workflow and Patient Management
- RN Case Management
- Electronic Health Records Management
- Coaching and Mentoring
- Critical Care Nursing
Work Availability
monday
tuesday
wednesday
thursday
friday
saturday
sunday
morning
afternoon
evening
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Timeline
Utilization Management (UM) Review Nurse - SureCo (UHSM)
07.2021 - Current
Special Account Quality Care/Auditor (weekdays) - Sedgwick (Formally York Risk Services Group)/CareWorks
09.2018 - 09.2020
RN Medical Case Manager - ExamWorks Clinical Solutions
08.2016 - 09.2018
RN Medical Case Manager - Corvel
01.2016 - 08.2016
RN Field Care Coordinator - APS Healthcare (as subsidiary of Universal American, Inc)
06.2013 - 10.2015
Regional Sales Executive - Wright Rehabilitation Services, Inc
06.2006 - 01.2012
Regional Sales Director - Southeast One Call Medical Inc.
11.2005 - 04.2006
Account Executive - One Call Medical/Occupational Solutions/Medquest Associates, Inc.
02.2003 - 11.2005
Center Administrator - MedQuest Associates, Inc.
05.2001 - 02.2003
Medical Management Specialist - Royal & SunAlliance Insurance
10.1999 - 05.2001
Workers Compensation Case Manger - RTW, Inc
05.1997 - 05.1999
Registered Nurse - StarMed Health Personnel
05.1997 - 10.1999
Registered Nurse - Lutheran Hospital
12.1996 - 03.1997
Registered Nurse - Cibola General Hospital
08.1996 - 11.1996
Registered Nurse - Dale County Department of Home Health State of Alabama
12.1995 - 08.1996
Registered Nurse - Dale Medical Center Hospital
03.1994 - 12.1995
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