Nina (Nickie) Robinson
Abilene
Summary
With over 22 years of diverse experience in direct patient care, staff supervision, and department operations, highly qualified and experienced Registered Nurse. Skill set includes multitasking and prioritizing patient needs and daily assignments. Expertise in Case Management, Quality Management, Auditing, and Utilization Management specialties to ensure the highest level of care for patients.
Overview
18
18
years of professional experience
Work History
QA Analyst RN
Conifer Health Solutions
11.2022 - 09.2024
- Performed retrospective (post -discharge/ post-service) medical necessity reviews to determine appellate potential of clinical disputes/denials or those eligible for clinical review
- Demonstrated proficiency in use of medical necessity criteria sets, currently InterQual or other key factors or systems as evidenced by Inter-rater reliability studies and other QA audits
- Constructed and documented a succinct and fact based clinical case to support appeal utilizing appropriate module of InterQual criteria (Acute, Procedures, etc)
- Pertinent clinical facts include, but are not limited to, documentation preventing a safe transfer/discharge or documentation of medical necessary services denied for no authorization
- Demonstrated ability to critically think and follow documented processes for supporting the clinical appellate process
- Adhered to the department standards for productivity and quality goals
- Ensured accounts assigned are worked in a timely manner based on the payor guidelines
- Demonstrated proficiency in utilization of electronic tools including but not limited to ACE, nThrive, eCARE, Authorization log, InterQual, VI, HPF, as well as competency in Microsoft Office
- UB92/UB04 and EOB components, adjustments, credits, debits, balance due, patient liability, denials management, etc
- Provided CRC leadership with sound solutions related to process
RN Clinical Guide
Devoted Health
04.2022 - 11.2022
- Company Overview: Remote
- Assisted UM Manager and managed day-to-day operations for UM team
- Engaged with members and understood their needs, using technology and data to better understand the member and any unspoken needs
- Performed initial, concurrent, and discharge reviews of all cases, including using medical guidelines to determine the medical appropriateness of inpatient and outpatient services; assessing, interpreting, and responding to the needs or requirements of patients; identifying, escalating, and resolving complex cases or issues as required
- Reviewed current charts for appropriateness and correct admission status (inpatient, observation, bedded outpatients)
- Collaborated with appropriate leadership concerning patients who do not meet medical appropriateness criteria
- Obtained admission and continued stay certification or recertification
- Communicated with physician regarding patients who do not meet criteria in order to identify additional documentation needs or potential changes
- Coordinated care and discharge planning
- Made arrangements for appropriate post-hospital care, including physical and behavioral medicine, transportation, equipment, home health care, etc
- Conducted holistic assessment to identify comorbid conditions, ED/ hospitalization history, medications, psycho-social factors, and member values and preferences
- Developed care plans in partnership with members and their caregivers - problems, goals, interventions - continuously evaluating the member's progress
- Collaborated with members, providers, and caregivers to ensure a positive outcome
- Educated members on appropriate care and settings based upon their healthcare needs
- Prepared members for their inpatient and outpatient treatments and coordinated post-treatment care
- Supported and coached members to improve management of their chronic conditions, including medication adherence and compliance.
UM Concurrent Review RN
UnitedHealth Group/WellMed
12.2019 - 04.2022
- Company Overview: Remote
- Used first-hand knowledge and clinical expertise to advocate for patients under care and enacted prescribed treatment strategies
- Reported findings to quality departments after conducting routine restraint audits and worked with a team to devise corrective actions for deficiencies
- Followed all personal and health data procedures to effectively comply with HIPAA laws and prevent information breaches
- Evaluated medical guidelines and benefit coverage to determine appropriateness of services
- Submitted cases for criteria failures and helped facilitate resolutions and approvals
- Performed admission reviews for medical necessity based upon MCG and Interqual criteria
- Supervised and maintained all utilization review documentation through TruCare software
- Participated in evidence-based practice project implementation, nursing competency development and nursing simulation activities
- Remote
RN Case Manager
Blue Cross Blue Shield of Texas
02.2019 - 12.2019
- Performed evaluations on a consistent basis to address changes in patient needs, conditions, and medications, altering care plans when required
- Created patient assessments and plans for individual home care needs
- Directed appropriate preventive and rehabilitative nursing processes and protocols
- Conducted regular re-evaluations to address changes in needs and conditions, introducing revisions to care plans
- Examined patients and documented history of current and previous conditions, illnesses, injuries, and current medications
- Created individualized care plans based on nursing diagnosis and incorporated appropriate nursing methods to achieve positive outcomes
- Advocated for patients by communicating care preferences to practitioners, verifying interventions met treatment goals and identifying insurance coverage limitations
- Worked with suppliers and vendors on provision of medical equipment, items and services
- Responded promptly and professionally to patient questions and concerns
- Took active role in patient and family planning process, detailing instructions, and responding appropriately and effectively to questions and concerns
- Educated patients and loved ones about different treatment options and outside care approaches to reduce burden on hospital resources.
Director of Home Health Care Services/Quality Management/Performance Improvement Director
Big Country Home Healthcare Services
01.2013 - 02.2019
- Company Overview: Abilene, TX
- Designed and introduced leadership development, coaching and team management model, resulting in promotion of employees into increased levels of responsibility
- Discussed medical histories with patients in effort to provide most effective medical advice
- Devised and introduced initiatives and projects to maintain or improve existing facilities, allowing for maximization of capital component of Medicaid's per diem rate
- Recruited, hired and trained all staff, providing direct supervision, ongoing staff development and continuing education to employees
- Implemented successful healthcare programs through professionalism, quality of care, medical teaching and patient satisfaction
- Created customized care plans, working with hospital staff and families to assess and meet individual needs
- Spearheaded and implemented new projects to expand scope of engagement
- Introduced and implemented new testing and interpretation procedures to maintain standards of care and meet quality assurance benchmarks
- Developed and updated policies and procedures, maintaining compliance with statutory, regulatory and local, state and federal guidelines relating to HIPAA, benefits administration and general liability
- Implemented best practice standards for billing resulting in substantial reduction of accounts receivable delays
- Abilene, TX
RN Field Nurse / Case Manager
Big Country Home Healthcare Services
01.2010 - 01.2013
- Company Overview: Abilene, TX
- Abilene, TX
LVN field nurse/Administrative Assistant to the DON
Big Country Home Healthcare Services
06.2006 - 01.2010
- Company Overview: Abilene, TX
- Abilene, TX
Education
Master of Science - Nursing Administration
Walden University
Minneapolis, MN02-2024
Bachelor of Science - Nursing Practice
Galen College of Nursing
Louisville, KY07-2017
Skills
- Specialized Management Skills
- Proactive Health Management
- Expertise in Acute Care
- IV Therapy Administration
- Effective Clinical Decision-Making
- Home Care Subject Matter Expert
- Employee Supervision
- Strategic Leadership
- Case Coordination
- Process Improvement
- Clinical Utilization Review
- Staffing Task Organization
- Staff Recruitment
- Training and Mentorship
- Effective Team Leadership
- Effective Discharge Planning
- Patient Support Services
- Patient Care Coordination
- Healthcare Operations Oversight
- Leadership in Nursing Staff
- Healthcare Education Initiatives
- Skilled in Google Docs Document Management
- Medical Records Management
- Insurance Plan Specialist
- Experienced with Microsoft Teams
Timeline
QA Analyst RN
Conifer Health Solutions
11.2022 - 09.2024
RN Clinical Guide
Devoted Health
04.2022 - 11.2022
UM Concurrent Review RN
UnitedHealth Group/WellMed
12.2019 - 04.2022
RN Case Manager
Blue Cross Blue Shield of Texas
02.2019 - 12.2019
Director of Home Health Care Services/Quality Management/Performance Improvement Director
Big Country Home Healthcare Services
01.2013 - 02.2019
RN Field Nurse / Case Manager
Big Country Home Healthcare Services
01.2010 - 01.2013
LVN field nurse/Administrative Assistant to the DON
Big Country Home Healthcare Services
06.2006 - 01.2010
Master of Science - Nursing Administration
Walden University
Bachelor of Science - Nursing Practice
Galen College of Nursing
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