Paula Cauley LPN
Riverview,USA
Summary
Results-driven nurse with expertise in evaluating medical necessity and conducting appeals reviews. Skilled in utilizing Interqual and MCG guidelines to assess hospital records and ensure compliance with Medicare and Medicaid guidelines. Proven ability to develop discharge plans and provide training to new nurses. Strong interpersonal and communication skills, coupled with proficiency in healthcare regulations and clinical documentation. Adept at multitasking, problem-solving, and time management, with a focus on delivering high-quality care and achieving positive outcomes.
Overview
31
31
years of professional experience
Work History
Utilization Review Nurse, Appeals review Nurse
Wellcare Health plans
08.2013 - Current
- Responsible for case development and resolution of various clinical cases, such as: Prior Approval, Medical Necessity(for both inpatient and outpatient services), Pre-certification, Continued Stay, Reduction, Termination/Suspension of services
- Manage caseload of 18-24 cases per day
- Assessed the appropriateness of hospital stays and outpatient services, based on established standards, using Interqual and MCG guidelines
- Interpret regulations, and reference internal health plans policies and procedures to frame decisions
- Reviewed appeal cases to ensure compliance with established medical necessity guidelines.
- Streamlined discharge planning to ensure seamless transitions to SNF, inpatient rehab units, and home care
- Prepare cases for Medical Director Review ensuring that all pertinent information (i.e. case summary, contract information, internal and external responses, diagnosis, and CPT codes and descriptions) has been obtained during investigation and is presented as part of the case
- Update file documentation such as the file notes and case summary
- Generate outcome letters for various lines of business
- Work within turn around times, and meet productivity and quality expectations each month
- Educated incoming staff in utilization management procedures.
- Additional duties as assigned
Benefits Authorization nurse
MetLife
10.2012 - 08.2013
- Manages assigned caseload of complex cases, applies specialized training/knowledge to the assessment of cases
- Investigates long-term care claims and makes benefit eligibility determinations based on physical and cognitive assessments within authorized guidelines
- Provide counseling to insured/family regarding all aspects of care delivery, financing, and medical/psychosocial issues
- Develop a plan of care based on insured dependencies, goals and objectives, available family support, financial and social needs, provider availability and insurance coverage
- Exercised sound judgment when making decisions regarding patient safety and well-being
- Utilized critical thinking skills to assess patients' needs and develop individualized plans of care
- Managed time efficiently while balancing multiple priorities simultaneously
LPN Field Nurse
Gentiva Home Health
02.2012 - 08.2012
- Assessing patients in home setting, teaching on disease management
- Teaching of meds and side effects, how to manage medications, proper diet, exercise
- Wound care, labwork, injections administered, obtained vitals, blood sugars, coumadin levels
- Report to RN daily, and doctors on regular basis, teach family members to care for patients
LPN Case Manager
Amedisys Home Health
07.2008 - 07.2012
- Assessed patients in home and assisted living environments- identifying medical, psychological, and social issues that need intervention.
- Had consistent caseload of seven to nine patients a day and covered six counties
- Assisted physician and RN in performing specialized procedures
- Health teaching on disease processes and symptoms of, meds, side effects, community resources and diet etc
- Assisted patients in learning appropriate self care techniques
- Helped to achieve and maintain continuity of patient care by assisting in planning and exchanging information with appropriate staff
- Makes updates on care plans that align with the physician’s treatment plans and recommends interventions that align with proposed goals as needed
Quality Improvement Nurse Auditor
Ware Visiting Nurses Services
07.2011 - 11.2011
- Responsible for utilization review of146 charts monthly for accuracy prior to submitting charts for Medicare billing
- Assured guidelines are followed according to medicare/HMO/medicaid and joint commission
- Writing plan of correction for errors made to ensure final billing could be submitted
- Conducted inservices on various healthcare topics related to patient care, therapy services, proper documentation
Wound care coordinator
Waycross Health and Rehab
10.2006 - 07.2008
- Responsible for skin and wound care of ninety bed facility
- In charge of wound care prevention, in terms of developing plan of care and or treatment
- Ensured staff followed plan of care
- Weekly skin assessments on all patients, coming up with appropriate treatments for each wound
- Health teaching to staff, family, and residents about prevention of pressure ulcers and skin tears
- Treatment of burns, surgical wounds, skin tears and other types of wounds
- Updating careplans as needed to reflect nursing interventions related to skin
- Maintained adequate nutrition and use of supplements to aide/promote healing
LPN Team Leader/Supervisor
Delaware Nursing and Rehab
11.2003 - 09.2006
- Ensured meds and controlled substances were ordered, received, administered, stored, and disposed of per policy
- Conducted rounds every two hours and as needed observing resident care
- Managed MD orders efficiently and accurately.
- Monitored and ensured compliance of CNA duties with planned care.
- Completed necessary paperwork including incident reports, care plan updates, and MD orders.
- Monitored performance of CNAs and LPNs frequently.
LPN Supervisor
Mc Auley Residence
11.1993 - 01.2003
- Organized CNA shift assignments.
- Conducted rounds alongside Physicians.
- Coordinated operations in doctor's office specializing in family medicine and pediatric care.
- Processed prescription refills, took patient vitals, and performed eye exams and lab work.
- Processed admission and discharge documentation efficiently.
- Conducted weekly performance audits for LPNs and CNAs.
- Delivered educational workshops on diverse topics based on demand.
Education
LPN certificate -
Erie1 BOCES center
Kenmore, NY09.1994
Skills
- Healthcare regulations
- Effective Multitasking and organizational management
- Clinical Documentation
- Quality auditing
- EMR / EHR
- Case Management
- Interpersonal and written communication
- Problem-solving abilities
- Commitment to Professional Standards
- Electronic Health Record Systems
- Utilization management and appeals review
- ICD-10
- Programs: MCG, Interqual, Excel, Outlook, one note, Jiva, Facets, Pega, care central
Timeline
Utilization Review Nurse, Appeals review Nurse
Wellcare Health plans
08.2013 - Current
Benefits Authorization nurse
MetLife
10.2012 - 08.2013
LPN Field Nurse
Gentiva Home Health
02.2012 - 08.2012
Quality Improvement Nurse Auditor
Ware Visiting Nurses Services
07.2011 - 11.2011
LPN Case Manager
Amedisys Home Health
07.2008 - 07.2012
Wound care coordinator
Waycross Health and Rehab
10.2006 - 07.2008
LPN Team Leader/Supervisor
Delaware Nursing and Rehab
11.2003 - 09.2006
LPN Supervisor
Mc Auley Residence
11.1993 - 01.2003
LPN certificate -
Erie1 BOCES center
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